Customer Details Form

Contact details

Title

First name

Last name

Company (where applicable)

Your position

Address 1

Address 2

Address 3

Address 4

Post code

Contact methods

Please complete at least one.

Telephone

Mobile

E-mail (billing & support queries)

Billing preferences

We accept Bank Transfer, Cheque, Credit/Debit Card & Direct Debit.

E-mail or postal billing? E-mail Postal

Payment method Bank Transfer/BACS Cheque Card Direct Debit

Billing frequency Monthly Quarterly Annually

Product(s) of interest

If not detailed elsewhere.

Consent

I confirm that I am authorised to supply the contact details on behalf of the person, entity or organisation detailed herein, and that I accept the Cornwall Broadband Limited privacy policy, detailed in their standard terms & conditions. Cornwall Broadband Limited will hold these details in accordance with the GDPR regulations and we never share your details with third party companies or for marketing purposes. Please tick here if you would prefer not to receive marketing or promotion information from us directly.

Signature

If using the manual signature box on the left, please print, sign, scan and e-mail or post the form.

For online submission, type your full name in the Signed field. This acts as your electronic signature.

Signed (type full name)

Print

Date

I agree that my typed name above is my electronic signature for this form.