Web Site Hosting Order Form

Website Hosting Online Application Form

To order a WebAssist web site and email hosting plan, please fill in the following Online Application Form

By submitting this form you declare that you have read and understand the Terms and Conditions

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

Contact Details:

Company/Business Name:

ACN / ARBN No.:

ABN No.*:

Contact Name*:

Position:

Street Address*:

Suburb*:

State*:

Postcode/Zip Code*:

Phone 1*:

Phone 2:

Fax:

Mobile:

E-mail:

Plan Selection:

Hosting Plan required*:

Static IP address required?*:

Domain Name Details:

Transfer/Delegate Existing Domain Name - Free Service
Domain Registry Key Code*:

Register and Delegate a New Domain Name - See Prices Below

.com.au / .net.au / .au.com - $138.70 for 2 years plus $33 admin/processing fee (inc. GST)
.com / .net / .org - $132 for 2 years plus $33 admin/processing fee (inc. GST)

Domain Name to Register or Transfer*:

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

I declare that I have read and understand the terms and conditions of use of the WebAssist services by submitting this online application form.
Please read the WebAssist terms and conditions here: Click here

Yes, I agree to the terms and conditions No, I do not agree to the terms and conditions

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

Transfer/Delegate Existing Domain Name - Free Service Domain Registry Key Code*:
Register and Delegate a New Domain Name - See Prices Below
.com.au / .net.au / .au.com - $138.70 for 2 years plus $33 admin/processing fee (inc. GST) .com / .net / .org - $132 for 2 years plus $33 admin/processing fee (inc. GST)
Domain Name to Register or Transfer*: