Secure domain account
Upgrade Order Form (SUDA2.7)

This form should be used only for upgrades of existing accounts. Please print and then complete all relevant sections. This complete document should be then either faxed through to NetCulture on +33 (0)1 4035 3194 , or sent via normal post to NetCulture, 18 pl de la Chapelle, 75018 Paris, France.
Name : ________________________________
E-Mail : ________________________________
Company : ________________________________ if applicable
Address : ________________________________
City : _____________________ Postcode: _____________________
Country : ________________
Telephone : _____________________ Fax: _____________________


Existing Domain Name :

________________________
Existing Admin account : ________________________
Existing Admin password : ________________________
Reseller Domain Name : ________________________ (for resellers only)


Description
Price
[___] Addition of Level 2 Secure Account System
(https://www.yourdomain.com)		 € 29.70 per month
[___] Addition of Level 2 Secure Account System - Reseller
(https://www.yourdomain.com)		 € 16.10 per month
Total Monthly € ______

First 3 months Total
€ ______
One Time Account Creation € 53.40
Total € ______
VAT @ 19.6% € ______
Total Amount Payable € ______

Visa or MasterCard
Please charge my [__] Visa or [__] Mastercard (please tick)
Name on Card [________________________________________]
Card Number [_____] [_____] [_____] [_____] Valid Until [___/___] (month/year)
Address if different from above [________________________________________]

Signature
[________________________________________]
Cheque (French Only)
[___] I enclose a cheque made payable to 'NetCulture' for the amount shown above.