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### Contact Information

## Admin

Contact Name:		__________________________________________________

Organisation Name: 	__________________________________________________

ABN/ACN/ARBN:		__________________________________________________

Email:			__________________________________________________

Postal Address:		__________________________________________________

			__________________________________________________

City:			___________________________   Postcode:	__________

Country:                ___________________________

Phone: 			___________________________   

Mobile:			___________________________

## Technical contact: (If different to above)

Contact Name:           __________________________________________________

Organisation Name:      __________________________________________________

ABN/ACN/ARBN:           __________________________________________________

Email:                  __________________________________________________

Postal Address:         __________________________________________________

                        __________________________________________________

City:                   ___________________________   Postcode: __________

Country:                ___________________________

Phone:                  ___________________________

Mobile: 		___________________________

## Billing contact: (If different to above)

Contact Name:           __________________________________________________

Organisation Name:      __________________________________________________

ABN/ACN/ARBN:           __________________________________________________

Email:                  __________________________________________________

Postal Address:         __________________________________________________

                        __________________________________________________

City:                   ___________________________   Postcode: __________

Country:                ___________________________

Phone:                  ___________________________

Mobile:			___________________________


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### Service selection

Hosting account:	Starter     Small       Medium    Large    Huge
(please circle one)	10MB	    50MB        125MB	  250MB    500MB
			$198/y      $363/y      $539/y    $715/y   $1540/y
			n/a         $32.50/m    $48/m     $64/m    $140/m

Desired Username:	_________________ (maximum of 8 characters)

Alternate Username:	_________________ (maximum of 8 characters)

Account password:	__________________________________________________


### Domain name options:

Domain name:		__________________________________________________

Other domains:		__________________________________________________

			__________________________________________________

Domain Options:      	__ Register this domain.
(please tick one)   
		     	__ I own this domain, please move it to Anchor.
			Please provide the username and/or password for
			your domain:
					__________________________________
		      
		     	__ I own this domain, I will move it to Anchor.
                      
		     	__ I will handle DNS elsewhere.

			Comments / Instructions:__________________________

			__________________________________________________
			

### Optional features:
(please tick one)
		     	__	JSP / Java Servlets	(only available on
					     Medium, Large or Huge plans).

		     	__	Database: PostgreSQL or MySQL
			(not available on starter plan)

### Email settings:

Please indicate how you would like email handled for your domain:
(please tick one, and provide details below)

		     	__     Forward email to existing accounts.

		     	__     Collect email from mailboxes/POP accounts.

		     	__     Existing mail server,(preserve MX records).

		     	__     No email required.

			Instructions / Comments:  ________________________

			__________________________________________________

			__________________________________________________

			__________________________________________________


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### Billing Information

Billing Frequency:  (please tick one, note: the starter plan is only 
available on Annual billing cycle).
		     	__ Annually

		     	__ Quarterly

		     	__ Monthly

			 
Payment Method:	     	__ Cheque/Money Order	
(please tick one)	 
		     	__ Electronic Funds Transfer
			 
		     	__ Credit Card

If paying by credit card, please provide details:

Card Type:	     	__ Visa
(please tick one)	 
		     	__ Mastercard
			 
		     	__ Diners Club

Cardholders name:       __________________________________________________

Card Number:            __________________________________________________

Expiry Date:            ___/___   Signature: _____________________________

Additional comments or instructions:

			__________________________________________________

                        __________________________________________________

                        __________________________________________________

### Terms and Conditions:

I have read and accepted the current terms and conditions located at:

http://www.anchor.com.au/terms

I am authorised to order this account on behalf of the listed contact / 
business.

Name:	____________________________	Position: ________________________

Signature: ____________________________	Date:	__________________________

Please return completed form to:	Fax:	(+612)  8296 5199

				Or by post to:	Level 4, 81 York ST
						Sydney, NSW 2000

If you have any questions please call us on 1300 883 979.

### Notes
*If you require Anchor to register a .com.au or .net.au domain name
for you, you need to supply us with a valid ABN, ACN or ARBN.
*Java servlets/JSP is not related to Javascript, and are not needed
for it. Javascript works on all our hosting accounts.