interconnections

Schillerstr. 44
D - 79102 Freiburg
Germany
Tel. +49 761 700 650, Fax - 700 688
info@au-pair-box.com
Version of Jan. 2nd 2007

Application Form for the "Au-Pair-Box"-Service

I wish to benefit of the "Au-Pair-Box"-Service. I have knowledge of the "Service-Description" as well as of the "General Terms and Conditions of Business" and filed them. The fees have to be paid on the basis of the actual price list. I understand that agencies with several offices pay € 11,90 for any more postal address on the agencies´ list or email address on the mailing list respectively. All prices include VAT, momentarily 19 %, if applicable. Else prices are gross for net.

Prices in Euro incl. VAT (in EU-Countries) Offer 1 Offer 2 Offer 3
Installation fee (once and for all) --- 59,50 119,00
Monthly fee 13,09* 30,94** 48,79
* Anual prepayment.   ** 6 months´ prepayment.


__________________________________

Company, Organisation

__________________________________
Telephone

__________________________________
Person in charge

__________________________________
Fax

__________________________________
No./street

__________________________________
Email

__________________________________
Postal Code, Town

http://______________________________
Homepage, Address for a Link

I am interested in:
Offer 1     O Offer 2     O Offer 3     O

Name of the subdomain under http://www.au-pair-box.com (compare "Service-Description" here).
My internet adress shall be named as follows:

http://www.au-pair-box.com/ ______________________________________

Agency´s Name in the Internet


_____________________________________________________________
Town, Date, Signature, Stamp

I wish to pay by:

O Check (in Euro !,
plus Euro 15 bank fees for any one check


__________________________________
Name of the bank


__________________________________
holder of the account


__________________________________
Bank code


__________________________________
account number

Should my account not be credited, my bank is not obliged to make any payments.

O Credit Card

I declare that the following details are correct and that I shall pay the fees which are due to interconnections for the utilisation of the Au-Pair-Box-Service.


__________________________________
Card holder (Name, first name)


__________________________________
number of card


__________________________________
Valid until (month/year)

O Visa, O Eurocard, O Mastercard,
O American Express, O Diners Club


__________________________________
Bank

This agreement is valid until notice of termination in writing (Registered letter with reply coupon). Fees are always due in their totality.


______________________________________
Town, Date, stamp, signature of account holder

_______________________________________
Town, Date, stamp, signature of credit card holder

Contract / Application Deutsche Fassung Service Description
Offer 1
Offer 2
Offer 3
General Terms