FAMILY NAME___________________________GIVEN NAME___________________

DOB_________

ADDRESS________________________________________________________

__________________________________________________P/C___________

PHONE( H)____________(W)_______MBL_________________FAX_________

Service Option:

Payment Details:

CHEQUE/MONEY ORDER ENCLOSED $____________

CREDIT CARD DETAILS: TYPE OF CARD________EXPIRY DATE______/______

NAME ON CARD____________________________

CREDIT CARD No _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _ AMOUNT $______________

USER NAME ______________________PASSWORD___________________________

PLEASE NOTE:The user name should be between 3-8 characters with the first
character being an alphabetical character. Only lower case alphanumeric characters
can be used.

Password :should be as follows but not neccessarily in the order listed here.

Minimum of 6 characters composing the following:
Capital Letter(s)
Lower Case Letters
Number
Symbol (eg #, *)

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