Name:

Date:

Address:

Phone:

Fax:

Please enter either the details of service required,  invoice number or attach a copy of the order form that you are paying for:

Details of Dial Up service:

Dial Up Service Only: Preferred User name

Details of Hosting service (e.g. SOHO hosting):

Invoice number (if applicable):

Domain name(s):

Official Order form attached:

Payment method:

Payment for 12 months (entitled to 10% discount - hosting accounts only):

Payment by Cheque or Money Order

I have enclosed a cheque for $___________

Please make cheques payable to SupplyLink International Pty Ltd and write your domain name or invoice number on the back of your cheque.  Mail your payment, together with this form and the printed order form to:

SupplyLink international Pty Ltd
PO Box 313
Beenleigh Qld Australia 4207

Payment by Credit Card

Type of card:	Bankcard    MasterCard    VISA
Name on card:	_________________________________
Card number:
Expiry date:	______/________/________
Cardholder signature:	__________________________________

Please tick one box:

	Please make a one-off charge to the credit card I have indicated above for the following amount:  $___________
	Please make a regular monthly charges to the credit card I have indicated above for the following amount until further notice:  $___________

Please mail this form to:

Beenleigh.biz
A Division of 
SupplyLink International Pty Ltd
PO Box 313
Beenleigh Qld Australia 4207

Thank you for your payment!