Daltron Global Roaming Application Form  

Credit Card Accounts Only

Please complete this form, along with your Daltron user details and return to Daltron via

Fax: 325 6558

OR

Post to:
Customer Account Services
Daltron Electronics
P.O. Box 1711
Boroko   NCD
Papua New Guinea
Daltron Global Roaming is only available for Windows 95/98, Windows NT and 2000 Users. Once Global Roaming has been enabled for your UserID, you must see the following site for further information before you travel overseas:
Daltron Global Roaming 
  Credit Card Accounts Only     
Daltron User ID: __ __ __ __ __ __ __ __ Given Name:

__________________

(eg. username@daltron.com.pg)
Telephone Number: ____________________ Surname:

____________________

I have read, understood and agreed to the terms and conditions related to Daltron Global Roaming.

Please debit my Credit Card K 80.00 (plus GST) for my annual subscription to Daltron Roaming

Credit Card Type: Amex* Mastercard Visa
* If American Express, your Amex ID No. shown on your card is _______________________ 
Credit Card Number:
Credit Card Expiration Date: / Month / Year
Card Holders Surname: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Signature: ________________________ Date: / /
If you have changed your Address, please let us know
New Address Details 
Address: _______________________________________________________________
City/Town: ________________________ Province: __________ Postcode: _________

Authorisation Number________________________________