Blue IQ - Dialup Internet Application

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Use the form below to sign up to Blue iQ Dialup Internet. After we have received the form, we'll contact you to confirm the details and collect payment information. If you have any questions please feel free to call us on 1300 Blue iQ.

Which service do you require?*
Please choose which service you require - Dialup Casual or Dialup Permanent.

Dialup Casual :

$19.95

Dialup Permamnent :

$69.95

Installation Options*
Please choose which installation option you would like.

Equipment Only :

$99.00

Professional Installation :

$199.00

No Installation :

$Free!

Your new email address
If you need or would like a new email adress, perhaps because you're leaving your old provider, or this is a new service, please choose an email address below. If you already have an email address that you won't lose by leaving your current provider, such as a Hotmail or Yahoo! address, or a company email address, you do not need to choose an email address here, although you're more than welcome!.

Preferred email address :

@ iq.net.au

Choose a Password
Please choose a password for your dialup service. If you are also having an iq.net.au email address, this password will be your email password too.

Password* :	Minimum 6 characters
Confirm Password* :

Contact Details
Please enter your contact details.

Name* :
Date of Birth* :	DD/MM/YYYY, e.g. 21/07/1982
Company :
Trading Name :
ABN :
Phone* :
Fax :
Mobile :
Email* :

Address Details
Please enter your address.

Address line 1* :
Address line 2 :
Address line 3 :
Suburb* :
State* :
Postcode* :

Billing Address Details
Please enter the address you would like invoices and postal correspondence sent to.

Billing Address line 1 :
Billing Address line 2 :
Billing Address line 3 :
Billing Suburb :
Billing State :
Billing Postcode :

Miscellaneous
Use this area to detail any special requests or instructions you may have.

Special Instructions

Terms and Conditions
Please indicate that you have read, understood and agree to be bound by Blue iQ's Terms and Conditions as posted from time to time at http://www.blueiq.com.au/termsAndConditions.html.

I have read, understood and agree to be bound by Blue iQ's Terms and Conditions :

Almost Done!
Just fill in the image verification box and click submit to send your application to us. After we have received your application, we will contact you to confirm details and collect payment information.

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