Landbase Australia

LANDBASE AUSTRALIA REGISTRATION FORM

LOCKED BAG 25 Gosford NSW 2250 Australia
Phone: (Australia) 0408 68 64 61 Office hrs. 0900-1700. AEST
After hours message bank in service
Fax: (Australia) 02 43 23 73 26
Phone: (International) +61 408 68 64 61 Office hrs. 0900-1700. AEST
After hours message bank in service
Fax: (International) +61 2 43 23 73 26
E-mail: lbase@ozemail.com.au URL: http://www.ozemail.com.au/~lbase/

PRIMARY USERS NAME: (including all initials)

ALL OTHER USER NAMES: (including all initials) Remember to include Company/Business Names, Trust Funds, Yacht Names, Vehicle Names, Nicknames or any other names/likely identification

CURRENT ADDRESS:

CURRENT PHONE NUMBER:

MOBILE NUMBER:

EMAIL ADDRESS:

INTENDED DATE OF DEPARTURE:

WHERE DID YOU HEAR ABOUT LANDBASE AUSTRALIA?

PLEASE CHOOSE ONE OF THE FOLLOWING OPTIONS

THREE MONTH REGISTRATION $90-00 LESS $5-00 DISCOUNT

SIX MONTH REGISTRATION $180-00 LESS $10-00 DISCOUNT

TWELVE MONTH REGISTRATION $360-00 LESS $30-00 DISCOUNT

ADVANCE POSTAGE DEPOSIT (AUSTRALIAN MAIL) $60-00 OR

ADVANCE POSTAGE DEPOSIT (INTERNATIONAL MAIL) $100-00

TOTAL ENCLOSED: (Please circle): Cheque/Money Order/*Mastercard/*Visa/*Bankcard
(No other cards accepted)

*Credit Card users. You will need to complete and return the Permission to use Credit Card Form, click here

WHEN/WHERE APPLICABLE ALL FEES ARE INCLUSIVE OF GST.
ALL FEES ARE QUOTED IN AUSTRALIAN DOLLARS.
THESE FEES WILL REMAIN VALID FOR THE FULL PERIOD OF YOUR CURRENT REGISTRATION BUT MAY BE SUBJECT TO CHANGE THEREAFTER.

ALL YOUR MAIL WILL BE HELD AT LANDBASE AUSTRALIA OFFICE UNTIL YOU PROVIDE US WITH A FORWARDING ADDRESS.

I ACKNOWLEDGE THAT LANDBASE AUSTRALIA WILL NOT BE HELD RESPONSIBLE FOR ANY PROHIBITED OR DANGEROUS GOODS SENT, OR LOST, DAMAGED OR STOLEN GOODS, AND, SHOULD ANY ILLEGAL ACTIVITIES BE CONDUCTED USING LANDBASE AUSTRALIA'S ADDRESS, REGISTRATION WILL BE DISCONTINUED IMMEDIATELY WITH NO REFUND APPLICABLE.

SIGNED: DATE ...../...../.....
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