Welcome to HealthVPN - Broadband Internet Ordering Form

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Order Broadband Online

This form will use your email service to forward to information to us.

Service Details
	SOHO MAX (up to 8Mbps)
	OFFICE MAX (up to 8Mbps)
	OFFICE PREMIUM (up to 8Mbps)
	FAST OFFICE (up to 24Mbps / 1Mbps)
	FAST OFFICE PREMIUM (up to 24Mbps / 2.5Mbps) with 512KCIR
	FAST OFFICE PLUS (up to 24Mbps / 2.5Mbps)
	Multiple IP Addresses
	Number of Line Filters Required
	ADSL Router
	Contact me to discuss Wireless Routers (please give email address or phone number in the box provided)

Order Details
	Invoice me (at the details below)
	Invoice my Organisation (at the details below)
	Order Number

Order Contact
	First Name
	Last name
	Organisation Name
	email
	Telephone number
	Fax number
	Address
	Post Code

Where is the service to be installed? (as it appears on your BT telephone bill)
	BT telephone number that the service is being added to
	First name
	Initials
	Last name
	Street/House Number
	Street Name
	Town
	Post Code

Billing Contact (if different from above)
	First Name
	Last name
	Different billing details from above
	Organisation Name
	email
	Telephone number (if different from above)
	Fax number (if different from above)
	Address (if different from above)
	Post Code (if different from above)

Terms and Conditions Apply
	I have read and agree to the terms and conditions

Millbeck Communications Ltd, Archway House, 30 High Street , Wetherby, LS22 6LT. Tel: 08453 47 00 74 Fax: 01937 902 041