Application for Internet account with BorgWiFi
all fields marked with * must be filled in .
Personal Details
( in this is a business account then please use the directors details)
Name: *
Title:
Address: *
Suburb: *
City: *
Phone: *
Mobile:
D.O.B:
Mothers Maiden name:
Business Details
(only required for business accounts)
Company Name:
Directors Name:
Address:
Suburb:
City:
Postal :
Phone Number:
Fax Number:
A/H Contact:
A/H Phone Number:
Company Registration Number:
IT Person:
IT Phone Number:
Account Type
(please select the account type, select Other and fill in the negotiated amount) Prices Include GST.
5Gb Home Account:
Flat Rate up to 5Gb (10cents per MB over 5Gb)
$ 49.95 / Month
Flat rate National:
Flat Rate National (8cents per MB international)
$ 79.95 / Month
Business Account:
Flat Rate up to 5Gb (10cents per MB over 5Gb)
$75.00 / Month
Corporate Account:
Flat Rate Business Account
$120.00 / Month
Other:
Other Accounts by negotiation
$
/Month
Web Hosting:
Web Hosting and Services
$
/Month
Account Details
Preferred Username: *
Existing e-mail address:
Preferred Password: *
Re-Enter Password: *
Technical Details
Operating System:
Wireless Device: (AP/PCMCIA/USB):
Mac Address: *
Computer Name / IDENT: *
Sign Here
I agree to pay all charges relating to my account. I understand that by using this account, I have agreed to be bound by and will abide by the Terms and Conditions that appear on the BorgWiFi’s web site at http://www.borg.net.nz/legal. If i have filled out this application on behalf of a business, I agree that I have the requisite authority to enter into contractual relations on behalf of this company with Borg Limited. I am over 18 years old and confirm that the information I have supplied is true and complete.
Full Name: *
Type the words ACCEPT: *
Date: *
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