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 *
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 - 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)
Subsidised @ $5.95
Citizen @ $9.95
Business @ $19.95
Corporate @ $29.95
Not Required @ Zero value
Any Further Information
...Payment Methods
Payment Method
(choose One)
* Bank Transfer
Credit Card
...by Bank Transfer in New Zealand
to The ANZ National Bank of New Zealand, Hamilton, New Zealand
account Ronald Gerritsen # 06 0996 0434182 00
Swift No. NBNZNZ22
...by Bank Transfer in Australia
to National Australia Bank, Williamstown, Melbourne, Vic
account Ronald Gerritsen 083-392 81 091 9377
Swift No. NATA AU 3303 M
...by Bank Transfer in the USA
to Chevy Chase Bank, Washington DC, USA
account Ronald Gerritsen # 259-3218185
Routing # / ABA #. 255071981
...by Cheque
by CHEQUE written to :
Ronald Gerritsen, 14 Queens Street, Cambridge 3404, New Zealand
Ronald Gerritsen, 15 Dickman St, Girgarre, VIC 3624, Australia
...by Credit Card
Credit Card Type  
Credit Card Number
(omit dashes & spaces)
Expiry Date  
Name on Card  

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