Order Online

Fill out this form if you are in our coverage area and have line of site to one of our transmitters. Otherwise please call or stop by to make an appointment for a free site survey at your home or business.

Company:
Title:
Contact Name:
Telephone:	Fax:
Are you an existing Wireless World customer?
Your email address:
Site Details - this is the location at which the equipment will be installed. Please complete one form per installation / location.
Site Address:
Town/Island:
Zip Code:
This is a:	Residence Business
Billing Details - Address to which invoices will be sent.
Use the above information for Invoices, otherwise fill out the following:
Name:
Company:
Mailing Address:
Town/Island:
Zip Code:
Order Details
# of Computers:	One Two or More
Any Servers:	Yes No
I also need a dial-up account at $19.96/mo: Yes No
Preferred VIAccess Username (8 chars max): 1. 2. 3.
New customers please note that as part of your WDSL service you are provided with one (1) viaccess.net e-mail address. Any additional Internet service will be provided at an extra cost.
Payment Method:
Type of Card:
Name on Card:
Account Number:
Expiration Date:

DECLARATION:

Acceptance of the Customer's order for the service to status and a satisfactory credit check, based on the details given above. Failure to complete all relevant sections may delay access to the service. I am authorized to apply for WDSL Services on behalf of the business named above which agrees to be bound by the conditions of service conditions in the Agreement. I agree that the details given above can be used for the credit checking. Private users/self-employed: I apply for WDSL Services and agree that the terms in the Agreement will apply to me. I am over 18 and the information I have provided above is complete and correct. I have had the opportunity to read and understand the TERMS & CONDITIONS in the Agreement. I agree that the details given above can be used for credit checking.

CHARGE CARD AUTHORITY

I hereby authorize you until further notice in writing to charge my credit/debit card with unspecified amounts in respect of WDSL Services as and when they become due.

SIGNATURE:_______________________________________________

PRINT NAME:________________________DATE:_________________

I have read the terms of service and by checking this box I acknowledge that I will abide by those terms along with the Declaration above and hereby grant that in lieu of a signature that I am bound to the terms and conditions of this service.

Dealer Code

Stamp of Security - Click here for more details

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