I (the reader and duly authorised person) hereby apply for the supply of a network connection and services in accordance with the Smartlinx3 Terms and Conditions Dated 01 July 2005 and the currently issued Schedule of Services and Charges. I declare that I know of no debt owing to Smartlinx3 Ltd in respect of previous failure to pay and I agree to pay for all services and connections as set out in the current Smartlinx3 Schedule of Services and Charges. I agree to give at least three month’s notice of intention to vacate, disconnect or reconnect the premises.

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 Smartlinx3, 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 Smartlinx3. Fax to 04 920 1740 or post to PO Box 40 240, Upper Hutt.

Full name of Client Company requiring Smartlinx3 Service *
Company Trading Name *
Contact Email Address *
Client Order Number *
Service requirement date *
Internet Service Provider (ISP) if known
Name of company arranging service if other than actual Client Company

Service Required – See Rate Card for more details.

	Connection Features (Tick as appropriate)	Additional Information	Install $	Mthly $
Direct Connection Speed	Smart 10 Smart 100 Smart 1000
Wireless Connection  Speed	DM 100 Sole 10 Sole 11 Sole 20 Sole 45 Multi 2 Multi 4 Multi 10
CafeNET Access Point	Yes No	Number. required?

Contract Term             12 mths 24 mths 36 mths

Please note: Installation can not be completed until a Customer Technical Details Form is submitted  

I hereby order the services I have indicated above and agree to abide by the Smartlinx3 Standard Terms and Conditions dated 01 July 2005:

Submit Cancel