Please print this order form, complete the details and either:

• fax to (National) 02 6562 8862 /( International) +61 2 6562 8862
• mail to Australiana Online, PO Box W156, West Kempsey NSW 2440, Australia

I Wish to Purchase the following Products:

Product Description                                       Qty      Price($AUD)

_________________________________    _____    _________

_________________________________    _____    _________

_________________________________    _____    _________

_________________________________    _____    _________

                                         Total excluding freight:  A$  _________

Please note the above total excludes the cost of freight. We will contact you via email

to confirm the freight charge before shipping your order. Any customs duty, tariff,

 taxes, or other charges levied by authorities are the responsibility of the purchaser.

Please tick one of the following 3 payment options:

I am paying by:

credit card ___   direct deposit ___     a cheque is enclosed ___

Please complete the card details below if paying by card. Direct Deposit and Cheques to be

Australian Dollars only. If paying by  direct deposit we will send you the bank account details.

If paying by cheque your order will not be processed until the funds have been cleared by the bank.

Card Details

All items marked with an * must be completed for your order to be processed.

Please circle the type of  credit card:

*Card type: Visa/MasterCard/bankcard/Diners Club/American Express/JCB

*Card Holder's Name:    _________________________________

*Card Number:         __ __ __ __-__ __ __ __-__ __ __ __-__ __ __ __

*Card Expiry Date:   __ __ / __ __

*CVV Code:            __ __ __ __ (the last 3 digit number located on the signature

panel of the Visa & MasterCard)

*Card Holders Signature:   ______________________________

*Billing Address

*No. & Street:         _______________________________

*Suburb/Town:        ________________________ State: _______

*Post/zip Code:       _________   *Country: ___________________

*Email Address:       _____________________________________

Telephone No.:         ___________________________

*Delivery Address:

*Receivers Name:     _______________________________

Company Name:        _______________________________

*Lvl No./Street No. & Name ______________________________

*Suburb/Town:          _______________________  State: ________

*Post/zip Code:         _________   *Country: ___________________

Special Instructions:   ____________________________________

  ______________________________________________________

 ______________________________________________________

 ______________________________________________________

How did you find Australiana Online?     ________________________

Australiana Online appreciates your business.