MICRONICA INTERNET/BBS MEMBERSHIP APPLICATION AND AGREEMENT FORM (v1.5) ----------------------------------------------------------------------- I agree to the MICRONICA terms and conditions of use. I understand that I am liable for all charges incurred on my account and that I will be billed accordingly. Please register me as a member. NAME/ORGANISATION/BUSINESS_____________________________________________ CONTACT PERSON IF BUSINESS_____________________________________________ STREET AND NUMBER (NO PO BOX!)_________________________________________ SUBURB_________________________________________________________________ STATE__________ POSTCODE________ CONTACT PHONE NUMBER (WORK)_________________ (HOME)____________________ CONTACT FAX NUMBER (IF AVAILABLE)(WORK/HOME)____________________ CHOICE OF EMAIL ADDRESS (SPECIFY ONE OR MORE) NOTE: The first part also acts as your login name. 1) ______________________________@micronica.com.au 2) ______________________________@micronica.com.au CHOICE OF PASSWORD (CASE SENSITIVE)____________________________________ METHOD OF SUBSCRIPTION PAYMENT ___CREDIT CARD ___CHEQUE OR POSTAL ORDER METHOD OF ONGOING BILL PAYMENT ___CREDIT CARD ___CHEQUE OR POSTAL ORDER CREDIT CARD DETAILS (IF PAYMENT BY CREDIT CARD) CARD TYPE (ONLY THESE CHOICES) ___VISA ___BANKCARD ___MASTERCARD CARD NUMBER ________ ________ ________ ________ EXPIRY DATE ____/____ CARDHOLDER NAME_______________________________________________________ WHO/HOW DID YOU GET REFERRED TO OUR SERVICE___________________________ TODAY'S DATE____/____/________ SIGNATURE_____________________ For enquires contact: Micronica Tel: 03-96998844, Email: micronica@micronica.com.au Web: www.micronica.com.au 184 Napier Street South Melbourne, 3205 Victoria AUSTRALIA Note: 1) Credit card payments carry a small surcharge. 3% as at 1/1/20. 2) All bills are normally emailed to the user's account. Please call and discuss any special billing requirements. 3) This application form can be posted or emailed back to us.