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Mail to:
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Exclusive Online Gold Coast Surf Reports
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Fax to:
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BURLEIGHCAM
PO Box 391
Burleigh Heads
Qld. Australia 4220
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Australian: (07) 5538 7571
International: +61 7 5538 7571
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ORDER DATE:.....................................................................................................
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ORDER INFORMATION:
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please complete all fields
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* Email:.......................................................................................
* Full Name:.................................................................................
* Address:...................................................................................
* Suburb/Town:............................................................................
* State:.......................................................................................
* Postcode:..................................................................................
* Country:....................................................................................
* Phone:......................................................................................
* Username:................................... (min. 3 characters, max. 12)
* Password:................................... (min. 4 characters, max. 12)
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BURLEIGHCAM SUBSCRIPTION
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[ ] YEARLY MEMBERSHIP: AU$49.95 /year
[ ] QUARTERLY MEMBERSHIP: AU$14.95 /3 months
[ ] MONTHLY CASH ONLY MEMBERSHIP: AU$5 per month. [ ] Number of months
(cash mail order: Liability is with the sender for cash mail order until we recieve the order. To minimise the risk
of theft please fold your cash into this order form once printed. Thank you.)
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[ ] Credit Card - We welcome Visa, Mastercard, Bankcard, Diners and AMEX.
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- Account Number:.............................................................
- Expiry Date:....................................................................
- Name on card:.................................................................
- CVV2 Number:.................................................................
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(CVV2 is a 3-4 digit number on back right of the card, or front for AMEX)
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[ ] Cheque
[ ] Money Order / Cash
[ ] Bank Transfer- Reference: yourusername, BSB: 484-799, A/c: 044920694
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PLEASE TYPE YOUR FULL NAME OR USERNAME AS REFERENCE FOR US ON THE "BACK OF CHEQUE".
PLEASE TYPE YOUR FULL NAME OR USERNAME AS REFERENCE FOR US IN THE "REFERENCE" FIELD PROVIDED ON THE BANK FORM.
OTHERWISE WE CANNOT CONFIRM YOUR PAYMENT AND YOUR ACCOUNT WILL NOT BE SETUP.
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I hereby declare that:
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I have read and agree to the BurleighCam Terms and Conditions as presented on the www.burleighcam.com.au web site.
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All information contained on this document is to the best of my knowledge true and correct.
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Signature:.................................................................
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Date:.............................
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Name:.......................................................................
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OFFICE USE ONLY
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Received By:............................................................
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Date:.................................
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