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...Business Information
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| Company
Name |
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| Business
Name |
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| Authorizing
Person's Name |
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| Physical
Address 1 |
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| Physical
Address 2 |
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| Postal
Address 1 |
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| Postal
Address 2 |
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| City
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| Postal
Code |
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| State
/ County / Province |
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| Country
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| Website
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| Email
Address |
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| Business
Phone |
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| Business
Fax |
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| Mobile
Phone |
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...Product Information
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Domain
name you wish to purchase
(DO NOT PURCHASE - we will do that for you)
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- CHECK
HERE - to see if available -
if you have not already done so. |
Website Hosting Plan
(that best suits your needs now - can be chnaged
in the future) (fees are monthly - paid for one year in advance)
(No GST is charged
(choose One) |
*
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| Any
Further Information |
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...Payment Methods
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Payment
Method
(choose One) |
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Bank Transfer
Cheque
Credit Card
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...by Bank Transfer
in New Zealand
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to The ANZ National Bank of New Zealand,
Hamilton, New Zealand
account Ronald Gerritsen # 06 0996 0434182
00
Swift No. NBNZNZ22
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...by Bank Transfer
in Australia
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to National Australia Bank, Williamstown,
Melbourne, Vic
account Ronald Gerritsen 083-392 81 091
9377
Swift No. NATA AU 3303 M
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...by Bank Transfer
in the USA
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to Chevy Chase Bank, Washington DC, USA
account Ronald Gerritsen # 259-3218185
Routing # / ABA #. 255071981
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...by Cheque
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by CHEQUE written to :
Ronald Gerritsen, 14 Queens Street, Cambridge 3404, New
Zealand
Ronald Gerritsen, 15 Dickman St, Girgarre, VIC 3624, Australia
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...by Credit Card
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| Credit
Card Type |
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Credit
Card Number
(omit dashes & spaces) |
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| Expiry
Date |
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| Name
on Card |
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