Ultra 1G Application form

Ultra 1G

I (the reader and duly authorised person) hereby apply for the supply of a network connection and services in accordance with CityLink's standard terms and conditions. I declare that I know of no debt owing to CityLink in respect of previous failure to pay and I agree to pay for all services and connections as set out in the Supply Agreement. I agree to give at least one month notice of intention to vacate, disconnect or reconnect the premises or services.

I understand that any personal information given to me is for a lawful purpose and will be used solely for the purposes of managing and supplying network connections and services and the business of CityLink, and I have a right of access to, and correction of, that information.

Transmission of a completed Customer Application Form constitutes an order for supply of services and will be acted upon by CityLink. Submit online, Fax to 04 385 9004 or post to PO Box 9328, Wellington.

I am Authorized to Make this Submission: *

Yes

Customer Details

Full Company Name: *

Trading Name: *

Are you an existing CityLink customer?: *

Yes

Client Order Number: *

Name of company arranging service (if other than actual client company):

What is the company's main business activity?: *