Online Product Order Form

Online Business
Online Order Form

Customer Details

Name Email Address Organisation Homepage, if any

Purchase Details

Please type in the number of units you wish to purchase in the box next to each product. Total value will be automatically calculated.

Code	Description	Price Per Unit($US)
P1	Unlimited Internet Access	$75
P2	20 Hour Internet Access	$25
P3	Pc To Phone 1500 Minutes	$200
P4	Pc To Phone 750 Minutes	$100
P5	Pc To Phone 375 Minutes	$50
P6	Pc To Phone 100 Minutes	$20

Billing Details

This information is generated automatically for your convenience!

Products Subtotal US$ Discount % Total US$

Credit Details

Method of payment Check via post Credit card via Fax Invoice me Credit card via online (fill details below)

Card Type Visa Mastercard American Express Card Number Cardholder Expiry Date

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