J o i n
 
 

Filling out this form will NOT get you instantly connected. After you fill out this form, you will need to print and sign it, then fax or post it back along with your payment details.
You will not be connected until payment has been received.
Our fax number is 9413-1564.
Our postal address is Suite 203, 3-9 Spring St Chatswood, NSW 2067
If you have any other questions, please give us a call on 9415-4733
 
Your Details
 
 
  First Name  
  Last Name
  Address
  Suburb
  Postcode
    Work Phone
  Home Phone
 
 Fax Number
  Mobile Number
    Email Address  
 
 
Account Details
 
    Flexi Plan $11> +88c > $33  
    30 Hour $11 per month  
       
    Username Option 1 (max 8 characters)  
    Username Option 2 (max 8 characters)  
   
A $22.00 Connection Fee applies to all customers. All prices include GST
  
   
I have read and hereby agree to the Terms and Conditions of Value Connect.
 
   

Signature

 
    Where did you hear about us?
Other. Please Specify
 
 
 
Payment Details
 
    Cheque  
    Money Order  
    Credit Card  
    Amount  
    Cardholders Name  
    Card Number  
    Expiry Date month year  
    Signature  
    Date