Summerland Amateur Radio Club
                    Internet Connect Form.              (inetconn.txt 7/99)

Date................. Referred by:................. Complete:..............

Surname:.......................Given name(s):..............................

Company name:..............................................................

Postal address:............................................................

Suburb:....................... State:.......... Pcode:.............

Date of birth:............... Sex: (M)..... (F).....

Phone (H):(     )..................... (W):(     ).........................

  Fax (H):(     )..................... (W):(     ).........................

Computer type:  (    )Mac.    (    )Win 95/98/NT   (    )Win3.11

Previous Service provider:....................... Email:...................

Preferred Username/Email:.......................................@nor.com.au
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                                Hour Rates.
   SARC Member rates-                             SARC Member Y/N (    )

       ......Hours @ $2.40 per hour = $.........
               (minimum of 10 hrs.)
                      Connection fee: $ 35.oo 
                                       ---------
                                Total $
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   Ordinary Rates-

 HOURS: ......... (10-49) @ $3.30 /hr $.........

        ......... (50-99) @ $3.00 /hr $.........

        ......... (100 +) @ $2.70 /hr $.........

                      Connection fee: $ 35.oo
                                       ---------
                                Total $
                                       ---------
NOTE: There are NO monthly or periodic charges or time expiry conditions.
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Payment Method:
              (  )Cash. (  )Cheque. (  )Visa. (  )Mastercard. (  )Bankcard.

Credit Card No.(.. .. .. ..)(.. .. .. ..)(.. .. .. ..)(.. .. .. ..)

Name on Card:...............................  Amount $...........

   Signature:....................  Expiry: ...../...../.....

Payment rec'd by Referrer Y/N(  ), To Treasurer (  ) Date ..../..../.... 
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 SARC will credit $5 for a succesful Internet Connect referral.
 Send to SARC, PO Box 524, Lismore,NSW. 2480. Email-  sarc@nor.com.au
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