World Internet Summit Australia 2005
Fax Order Form
Billing Information (* Indicates a REQUIRED FIELD)
* Full Name:  
Company:  
* Day Phone:  
Home Phone:  
Fax:  
* Email:  
* Repeat Email:  
* Address1:  
Address2:  
* City:  
* State/Province/County:   * Postal/Zip Code:
* Country:  
* Where did you hear about us?  
Credit Card / Payment Information
Name on Card   
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Visa Master AMEX
Card Number 
                               
Expire Date (mm/yyyy) 
 
   

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Signature      

I am sending a Cheque or Money Order

*This option is only available for one off payment.
Please make it payable to World Internet Corp. P/L.

Payment Option (Please Tick one)

One off Payment of $1,997 in Australian Dollars

I would like to take the advantage of your Easy Payment Plan, where I pay the initial deposit of $999 now. Then the other 50% in 30 days time - paid in full prior to event. (The cut off date for this offer is January 31, 2005 - and is only available to credit card orders) TOTAL: $1,998.
I am one of the first 50 people to register so I would like to bring my friend as a Free Guest.

My Friend's name is ___________________________________

My Friend's nemail is ___________________________________

I authorize World Internet Corp. Pty Ltd to charge me for the above total. I further affirm that the name and personal information provided on this form are true and correct. I further declare that I have read, understand and accept World Internet Corp. Pty Ltd's business terms as published on the web site. World Internet Corp. Pty. Ltd., a registered company incorporated in Victoria Australia
(A.C.N. 108 231 670) is the co-organiser of The World Internet Summit 2005. ()

Please Fax this form to (03) 94173360 or mail to 380 Johnston Street, Abbotsford, Victoria 3067, Australia