Welcome to HealthVPN - Token Only VPN Service Form

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Token Only VPN Service

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

This form is used for data collection and will only be used to create a Cable & Wireless contract for the service.

The completed contract will be emailed back to the person named as the Main Contact for their signature.

Ordering the Token Only Service

Complete the online form below or use the form for ordering On Site VPN Concentrator

Order Contract Details
	Order Number (optional)
	Clinical System Provider
	Have you read and understood the Scope of Service document?

Order Quantities
	User Tokens Required
	Administrator Tokens Required	(Enter 'M' if managed by Millbeck)
	Number of AVG AntiVirus software licences required	You must have up to date anti-virus software installed on your computer
	Number of AVG AntiVirus + Firewall licences required	You must have a valid firewall service on your computer
	Number of AVG AntiVirus + Firewall + Spy Sweeper licences required	As above, with the added benefit of an anti Spyware service

Broadband Internet Requirements and Additional Equipment
	Please contact me to discuss my Broadband Internet and Additional Equipment requirements

Main Contact This contact will be the main liaison with us for the order
	First name
	Last name
	Organisation Name
	email
	Telephone number
	Fax number
	Address
	Post Code

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

Administrator Details (Not needed for Millbeck Managed)(if different from above) Each administrator requires an Administrator Token
	First Name
	Last name
	Different administrator details from above
	Organisation Name
	email
	Telephone number
	Fax number
	Address
	Post Code

	Do you need additional administrators

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