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  
 Email  
 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

   
       

  
 

 
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