Website Hosting Online Order Form - For Resellers

Please fill in the following Online Order Form, once received we will contact you for further details.

By submitting this form you declare that you have read and understand the Service Agreement

Please make sure that you fill in all the required fields (marked by *)

          Your reseller code* 

Client Details:

Company Name:
ACN / ARBN No.: 
ABN No.:
Contact Name*:
Position:
Street Address*:
Suburb*:
State*:
Postcode*:
Phone 1*: 
Phone 2:
Fax:    
Mobile:
E-mail: 

Plan Selection:
(the reseller discount will be applied at time of processing)

Plan required*: 

Domain Name Details:

Transfer/Delegate Existing Domain Name - Free Service
Register and Delegate a New Domain Name - See Prices Below

.com.au / .net.au / .au.com - $137.50 (inc. GST) for 2 years
.com / .net / .org - $100 for 2 years
Domain Name to Register or Transfer*:

Additional Information: (that should be brought to our attention)

 

All pricing includes GST if applicable.

Upon successful submission we will be in contact with you to obtain any further information that may be required for the processing of this account. Accounts will be billed by your chosen billing method. If you have any questions or concerns regarding your order, please email accounts@WebAssist.com.au