Sections that are marked with an * are required fields.
Title: Mr Mrs Miss Ms Dr
First Name: *
Surname: *
Address: *
Address:
Town / City: *
Postcode: *
Phone: *
Mobile:
Email:
Is the connection going to be at the above address? If not, please enter area or areas below.
Area:
It would be appreciated if you fill out the following section of the register, in order to help us improve our services. This is not a requirement.
1. How do you currently connect to the Internet?
Dial Up
Broadband / ADSL
No Current Connection
2. How much data do you download per month?
0 - 100mb
100mb - 1gb
1gb - 5gb
5gb plus
Unsure
3. How much time do you spend on the internet per month?
None
Less than 1 hour
1 to 5 hours
5 to 10 hours
10 plus hours
4. How many internet users in your household?
1 to 3
3 plus
5. Who is your current internet provider (ISP)?
6. When does your current contract expire?
7. How did you hear about eBurnie?
Brochure / Flyer
Advertisement
Newspaper
Radio
Word of Mouth
Other
8. Are you interested in any extra eBurnie services?
Web Hosting
Off-Site Backup
Domain Name Registration
To find out more about our Point to Point and Outsourcing solutions please call us on 1300 852 369.