Customer Information

Internet Application Form

I am a New Customer
Existing Customer. Sancom Account No

Account Contact and Personal Details

Title

First Name

Last Name

Date Of Birth

Drivers License No

Home Address and Details. (Not P.O.Box)

Address

Suburb

State

Post Code

Land Phone

Mobile

Fax

Work No

Company Name

Select your Internet Plan

Dial Up Internet
	Unlimited Hours / Unlimited Downloads.	$15.00 / mth	[more info]


ADSL Broadband
	Speed	Plan	Download*	Monthly
	256/64	Sancom 256 Lite	200 MB	$24.90	[more info]
	256/64	Sancom 256 MAX	Unlimited	$40.00	[more info]
	512/128	Sancom 512 Lite	500 MB	$32.90	[more info]
	512/128	Sancom 512 MAX	Unlimited	$50.00	[more info]
	1500/256	Sancom 1500 Lite	1000 MB	$59.90	[more info]
	1500/256	Sancom 1500 MAX	Unlimited	$85.00	[more info]
	8000/384	Sancom 8000 MAX	Unlimited	$130.00	[more info]
Telephone Number where ADSL is to be Connected. Do you currently have ADSL on the above Number Yes, with another provider. Name of Service Provider No

Modem and other Accessories

I don't need a modem

$0.00

Dial Up Modem

Internal 56 K PCI Modem
$15.00

External Modem
$59.00

ADSL Broadband Modem

WebExcel 3812 ADSL Modem / Router.
Specifications: 1xUSB Port, 4xEthernet Port
$49.90 [more info]

WebExcel 2108 ADSL2/2+ Modem/Router.
Specifications: ADSL2 4xEthernet Port
$99.90 [more info]

WebExcel 2112 ADSL2/2+ Wireless Modem/ Router.
Specifications: 4xEthernet Port, 1xAntenna
$129.90 [more info]

Other Accessories

ADSL In Line Filter
$4.90 [more info]

Wireless Ethernet Card for Desktop IEEE 802.11g, 54M Wireless
$24.90 [more info]

Need more accessories and networking products? Click here to Visit out online shop.

Payment Details & Direct Debit Visa Card Master Card
Name On Card
Credit Card No Expiry Date MM/YY
Yes, I agree to Direct Debit terms and Conditions and I agree that I am the authorised user of the above credit card. Click here for Terms & Conditions.

Summary

Connection Fee
Internet Plan
Modem
Other Accessories
	Sub Total