Abel Internet Services
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For the Attention of Abel Staff Member
Staff Member:
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1. Client Details
2. Contact Details
Title:
Email Address:
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First Name:
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Daytime Tel.:
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Last Name:
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Evening Tel.:
Fax Number:
3. Company Information
Company Name:
4. Postal Address
5. Payment Details
Address:
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Terms of Payment: In Advance Payment Method:
CHEQUE
Payment Frequency:
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Once Only
Monthly
Quarterly
Yearly
Every 2 Years
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CREDIT CARD
Name on Card:
Postcode:
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Card Type:
Card Number:
Start Date:
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01
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2016
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Expiry Date:
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Security Number:
Issue Number:
6. Service to which payment refers
7. Account Name - e.g., bloggs.abel.co.uk
Service:
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Account Name:
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8. Security Information - Pertaining to the Service Provided
Date of Birth:
Mother's Maiden Name:
Memorable Phrase:
9.Your Comments & Purpose of Payment
Declaration:
I hereby confirm that I have read and understood Abel's Terms & Conditions relevant to the service for which I am subscribing. I agree to be bound by the said Terms & Conditions. Please until further notice debit my credit / debit card at the applicable rate and chosen payment frequency.
Advice:
You are strongly recommended to print a copy of this page.