Customer Application Form


 
      
Please complete the details below so that we can process your application
 


               Title :

 

 

    First Name * :

 

 

         Surname * :

 

 

       Address* :

 

 

                                 

 

 

                                  

 

 

Post Code * :

 

 

         Country  :

 

 

         Company Name  : 

 VAT registered :

 Yes   No 

        Telephone  :

  Mobile :

         Fax   :

  Email * :

       

Please select the service of your choice:

Service Type :

Adult Chat  Psychic Chat  Soft Chat     

 

Keywords : Please list the top three preferred keywords of your choice.

1St Choice :

 

 

2nd Choice :

 

 

 3rd Choice :

 

 
       

Tariff :

 £1.50       £1.00

 Further Tariff’s are available on request.

       

Would you like to add any initial free messages for end users who join your service?    
These messages are deducted from your revenue at five pence each.

 

   

Specific Requirements :

 

 

 

   

Revernet Agreement :

   

Please read the terms and conditions set out below. We will also send a copy of the contract that will require a signature.

 

       

Disclaimer :