your company name goes here - - - WEB CONTROL PANEL


SECURE ON-LINE PURCHASE ORDER FORMhttps-ssl-thawte




YOUR PERSONAL DETAILS not for publication: Please fill in all the required details, then click the SUBMIT button. Thank You.

Your First Name
Your Last Name
Daytime Telephone * Please don't put any blank spaces or dashes.
Mobile Telephone * Please don't put any blank spaces or dashes.
Fax Number * Please don't put any blank spaces or dashes.
Your Email Address * PLEASE NOTE: this is where your Tax Invoice/Receipt will be sent.
You must enter Your Email Address AND your Daytime Telephone Number.



YOUR COMPANY DETAILS: for publication on your website order page on our server

Daytime Telephone * Please don't put any blank spaces or dashes.
Mobile Telephone * Please don't put any blank spaces or dashes.
Fax Number * Please don't put any blank spaces or dashes.
Company ABN Number * If Applicable
Company Name * If Applicable
PO Box Address * If Applicable
Home Address
Home Address
Suburb / City
State * Please don't put any blank spaces or dashes.
Postcode / Zip Code * Please don't put any blank spaces or dashes.
Country
We can accept on-line credit-card orders from Australia, New Zealand, UK, USA and most other countries



YOUR ORDER DETAILS please select required level of service:

Qty # Unit Price - - - Catalogue Number and Description Total Price
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10

YOUR PAYMENT DETAILS:

Grand Total Amount (includes GST) Dollar Value to be charged:

Your Credit Card Type * This must be a Credit Card NOT an Eftpos Card.
Your Credit Card Number - - - * Please don't put any blank spaces or dashes.
Verification Code * This is the additional three digit number that follows the 16 digit credit card number as printed
within the signature strip on the BACK of the card. Some credit cards do not have this code number.
Expiry Month
Expiry Year
Name on Card
Your full name:
required

Your Alternate Email Address:
required

Where are you? [ suburb, city, state, country ]


Maximum Freight Charges per delivery:


If there is a problem with your order,
what is the best way to contact you?

Email
Facsimile
Telephone Message
Letter

YOUR ORDER COMMENTS:


Please use this form only if you want to place an order using your credit card. If you would like further information on our products or any other details . . .
Please Click Here for our email address


Data Security and Data Encryption: The security of your private information, and your money transactions are the core of our business and our top priority.
For additional security, and before encryption, your entire credit card number is deliberately split apart and encoded into separately sent multiple parts.

Before transit, this secure form automatically encrypts and then immediately sends your encrypted confidential information from your computer directly to our secure
internet web server using the Secure Sockets Layer protocol (SSL) with an encryption key length of 128-bits (the highest level commercially available).

Our secure internet web server sits behind an electronic firewall, and our secure server is heavily guarded both physically and electronically.

To maintain confidentiality during transmission over the Internet, your private information is encrypted using the SSL Thawte Digital Certificate.

Before you can be given secure access to the order-confirmation webpage, our secure internet web server checks that you are using an approved internet browser that is able to use SSL 3.0 or higher.

PLEASE NOTE:- The image of the locked padlock for the SSL Thawte Digital Certificate, can only appear (below) when you are using an approved internet browser that is able to use SSL 3.0 or higher.

https-ssl-thawte
purchase-secure

PLEASE NOTE: Any person who has completed this Form of Application published on the pSecure website URL http://www.purchase-secure.com.au/ by clicking the submit button thereon warrants that he has agreed to become a Customer of pSecure upon the Terms and Conditions of the Agreement for supply of Services.

After you submit this fully completed form, (~) you will receive a tax invoice AND/OR customer receipt number, plus (~) an automatic confirmation email will also be sent to you.
This purchase order form works best with MSwindows Internet Explorer Browser Version 5+


your company name goes here - - - WEB CONTROL PANEL
purchase-secure.com.au PTY LIMITED - - - ABN-94-098-625-426
P.O. Box 289 - Strawberry Hills N.S.W. 2012 Australia.
your street address - Strawberry Hills N.S.W. 2012 Australia.
Within Australia - Telephone-0500-88-88-08-PREPAID-NEW-SALES
Within Australia - Telephone-0500-88-55-00-PREPAID-SUPPORT
Within Australia - Telephone-0500-55-55-66-PREPAID-SUPPORT-HELPDESK
Telephone International +61-500-88-88-08-PREPAID-NEW-SALES
Telephone International +61-500-88-55-00-PREPAID-SUPPORT
Telephone International +61-500-55-55-66-PREPAID-SUPPORT-HELPDESK
Within Australia - Fax SYDNEY (02) FAX NUMBER

This website © Copyright 2000 to 2006

Website home-page address:- http://www.YourDomainAddress.com.au/~yourNAMEhere/
Sales email address:- mailto: yourNAMEhere @ purchase-secure.com.au
If you experience any WebSite problems, please immediately email the webmaster


Copyright 2000 to 2006

This secure webpage was Last Modified on Monday, 10-Jul-06 03:01:36 GMT


This secure webpage - - - Transaction Date and Time Monday, 27-May-19 18:57:07 EST