Hi Image Internet Services

Domain Name and Webhosting Order Form

...Business Information
Company Name  
Business Name  
Authorizing Person's Name *
Physical Address 1 *
Physical Address 2
Postal Address 1 *
Postal Address 2
City *
Postal Code *
State / County / Province *
Country *
Website
Email Address *
Business Phone *
Business Fax
Mobile Phone
...Product Information
Domain name you wish to purchase
(DO NOT PURCHASE - we will do that for you) 		  CHECK HERE to see if available
Website Hosting Plan
(that best suits your needs now - can be chnaged in the future) (fees are monthly - NZ$ plus GST)
(choose One)		 *
Subsidised @ AU/NZ$5.95 (US$3.95)
Citizen @ AU/NZ$9.95 (US$6.95)
Business @ AU/NZ$19.95 (US$12.95)
Corporate @ AU/NZ$29.95 (US$19.95)
Not Required @ Zero value
Any Further Information
...Payment Methods
Payment Method
(choose One)		 * Bank Transfer
Cheque
Credit Card
...by Bank Transfer
to The ANZ National Bank of New Zealand, Hamilton, New Zealand
account Hi Image Enterprises Limited # 06 0583 0460454 00
Swift No. NBNZNZ22
...by Cheque
by CHEQUE written to :
Hi Image Enterprises Limited, PO Box 2380, Wakatipu, Queenstown, 9349, New Zealand
...by Credit Card
Credit Card Type  
Credit Card Number
(omit dashes & spaces)		  
Expiry Date  
Name on Card  
  


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