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
 
Existing Users Only
  Please quote your site abbreviation code (e.g. nhsxxx)
 
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 (if different from above)
  Last name (if different from above)
  Organisation Name (if different from above)
  email (if different from above)
  Telephone number (if different from above)
  Fax number (if different from above)
  Address (if different from above)
  Post Code (if different from above)
     
Administrator Details (Not needed for Millbeck Managed)
Each administrator requires an Administrator Token
  First Name (if different from above)
  Last name (if different from above)
  Organisation Name (if different from above)
  email (if different from above)
  Telephone number (if different from above)
  Fax number (if different from above)
  Address (if different from above)
  Post Code (if different from above)
   
Second Administrator Details (if required)
Each administrator requires an Administrator Token
  First Name (if different from above)
  Last name (if different from above)
  Organisation Name (if different from above)
  email (if different from above)
  Telephone number (if different from above)
  Fax number (if different from above)
  Address (if different from above)
  Post Code (if different from above)
   
Third Administrator Details (if required)
Each administrator requires an Administrator Token
  First Name (if different from above)
  Last name (if different from above)
  Organisation Name (if different from above)
  email (if different from above)
  Telephone number (if different from above)
  Fax number (if different from above)
  Address (if different from above)
  Post Code (if different from above)