160.com.au
ABN 34 101 997 175

Suite 18, Level 2, 281 - 287 Sussex St, Sydney NSW 2000
Tel: 02 9283 9292
Email: authorization@160.com.au

ORDER FORM
FAX TO: 02 8014 4594
or mail to the above address



Title:      [  ] Mr    [  ] Mrs    [  ] Miss    (please tick appropriate)

First Name ___________________________    Last Name___________________________________

Home Address: ______________________________________________________________________________

Suburb: ______________    State ______    Post Code______

Email: ________________________________________________________________

HOME Phone: (       ) _____________________ Facsimile: (       ) ___________________

Work Phone: (       ) __________________________


Phone CardQtyPrice
    $    
TXT 100 SMS PACKAGE    $    
Phone CardQtyPrice
TXT 1500 SMS PACKAGE    $    
TXT 2000 SMS PACKAGE    $    
Phone CardQtyPrice
TXT 350 SMS PACKAGE    $    
TXT 5000 SMS PACKAGE    $    


Payment Details

Credit Card Type:      [  ] Visa    [  ] Mastercard    [  ] Bankcard    [  ] American Express    [  ] Cheque/ Money Order (please tick appropriate)

Credit Card Number: __ __ __ __/ __ __ __ __/ __ __ __ __/ __ __ __ __

CVV/CVC : __ __ __ __ (This is the 3 or 4 digit security code that appears in the front or back of your credit card)

Name (as it appears on the Credit Card) _________________________________

Amount $______________       Expiry Date __ __/ __ __

Authorised Signature: ________________________________