This form will use your email service to forward to information to us.

Service Details
 
 
 
 
 
 
  Multiple IP Addresses
  Number of Line Filters Required
  ADSL Router
  Contact me to discuss Wireless Routers
(please give email address or phone number in the box provided)
     
Order Details
  Invoice me (at the details below)
  Invoice my Organisation (at the details below)
  Order Number
 
Order Contact
  First Name
  Last name
  Organisation Name
  email
  Telephone number
  Fax number
  Address
  Post Code
     
Where is the service to be installed? (as it appears on your BT telephone bill)
  BT telephone number that the service is being added to
  First name
  Initials
  Last name
  Street/House Number
  Street Name
  Town
  Post Code
     
Billing Contact (if different from above)
  First Name
  Last name
  Different billing details from above
  Organisation Name
  email
  Telephone number (if different from above)
  Fax number (if different from above)
  Address (if different from above)
  Post Code (if different from above)
     
Terms and Conditions Apply
  I have read and agree to the terms and conditions
Millbeck Communications Ltd, Archway House, 30 High Street , Wetherby, LS22 6LT. Tel: 01937 534915 Fax: 01937 902 041
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