This form will use your email service to forward to information to us.
Service Details
Home 500
Home 1000
Office 500
Office 1000
Office 2000
Static IP Address
Number of Line Filters Required
ADSL Modem
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?
BT telephone number that the service is being added to
First name (as it appears on your BT telephone bill)
Initials (as they appear on your BT telephone bill)
Last name (as it appears on your BT telephone bill)
Street/House Number (as it appears on your BT telephone bill)
Street Name (as it appears on your BT telephone bill)
Town (as it appears on your BT telephone bill)
Post Code (as it appears on your BT telephone bill)
Billing Contact
First Name (if different from above)
Last name (if different 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
