Nashua Mobile Internet Application Form:

The cure to Internet-lessness is not far away now.

Step 1: Simply complete the form below, select your required services, accept our terms & conditions ..... and you are one step closer!
Customer Details:
Existing Client:    
If Yes, State Acc No.: If Yes, State Cell No.:
Contact Person: **ID No.:
Work Phone No.: Home Phone No.:
Fax No.: Cell No.:
Physical Address: Postal Address:
Physical Code: Postal Code:
Email Address:    
Employer Name: Occupation:
Employer Address: Postal Code:
Gross Monthly Income: Duration of Employment:
Bank Details:
Method of Payment:  
Name of Account Holder: Bank:
Branch Code: Branch Name:
Type of Account:: Bank Account No.:
Credit Card Type:    
Credit Card Number: Credit Expiry Date:
Services Required: #
Internet Connectivity: Hosting:
Email Hosting: Fax to Email / Email to Fax:
Domain Registration: Search Engine Submissions:

I require further information on the following services offered by Nashua Mobile Internet.
Website Design: Server Farming:
Hardware / Software Supply: Diginet Circuit:
Desktop / Network Support: Banner Servering:
Mail Servers: SQL / .NET Development:
Offsite Secure Backup: