World Netsafe Pty Ltd                                                           ORDER FORM
ACN 087 515 848                                                                                     Please Print Clearly using CAPITAL LETTERS
320 Adelaide St Brisbane 4000                                                                              
Qld 4000 Australia
Tel: 617-3001-7888 Fax: 617-3001-7878                                                     
Email: info@worldnetsafe.com

 


Family/Business Name

Middle Name

First Name

Home Phone

 

 

 

 

 

Member ID Number

Work Phone

Fax Number

E-Mail Address

 

 

 

 

 

 


Sponsor Information This person is your introducer to the Retail Sales Plan

 

Family/Business Name

Middle Name

First Name

  RICHARDSON

 

    SIMON

 

Member ID Number

Contact Phone Number

 

  simon@paidtosurf.co.uk

Card Applied For:- Tick One Box

Premier Card

Silver Card

Gold Card

Platinum Card

$75

$500

$1000

$1500

 

 

Method of Payment:-  Tick One Box

MasterCard

Visa

Bank Card

Amex

Diners Club

 

 

 

 

 

 

Name On Card

Card Number

Expires

 

 

 

 

Card holders Signature

 

Member Acknowledgement:-

I agree that I have read and fully understand the Terms & Conditions on the Policies & Procedures Document.  I certify that I have sold or used at least 70% of previously ordered product.  I have maintained copies of orders which I will make available upon request to the legal Compliance Division Of World Netsafe Pty Ltd.

 

Signed………………………………………..    Dated……………………………….

 

For Office Use Only

Received By…………

Date……

Amount Received………….