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First Name:
Surname:
Date Of Birth:
Country of Birth:
Please Select
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Brazil
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island (Australia)
Cocos Island (Australia)
Colombia
Comoros
Congo (Brazzaville),Republic of the
Congo, Democratic Republic of the
Cook Islands (New Zealand)
Costa Rica
Cote d'Ivoire (Ivory Coast)
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Indonesia)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia, Republic of
Germany
Ghana
Gibraltar
Great Britain and Northern Ireland
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Martinique
Mauritania
Mauritius
Mayotte (France)
Mexico
Moldova
Monaco (France)
Mongolia
Montserrat
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
North Korea (Korea, Democratic People's Republic of)
Norway
Oman
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Helena
Saint Kitts (St. Christopher and Nevis)
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia-Montenegro
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia (Falkland Islands)
South Korea (Korea, Republic of)
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau (Union) Group (Western Samoa)
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna Islands
Western Samoa
Yemen
Zambia
Zimbabwe
Private residential address:
Personal Mobile Number:
Company Name:
Company Type:
Sole Trader
Limited Partnership (LP)
Limited Liability Partnership (LLP)
Private Company Limited by Shares (Ltd)
Public Limited Company (PLC)
Private Company Limited by Guarantee
Charity
Company Registration Number:
Or Charity registration
Trading Time:
New Startup
Less that 12 months
12 - 36 Months
36 - 60 Months
5 years +
Previous registered address:
Company Information:
Please describe your companies activities
Primary EMail address:
Company Logo:
Telephone Company Name
Please enter exactly how you would like your telephone line to be answered
VIP Type:
Please select the package you require, click http://www.ecoinnovationcentre.co.uk/virtual_matrixa4.pdf for a package comparison.
VIP Bronze £30
VIP Silver £50
VIP Gold £85
VIP Platinum £150
Starting Date:
Please enter the date you wish your Virtual Tenancy to commence.
...
Carbon Zero Webhosting:
Bronze, Silver, Gold & Platinum VIPs are entitled to FREE webhosting (including full transfer of your website from your existing hosts, please indicate if you are interested.
Yes, I am interested in FREE carbon zero webhosting
No, I am happy to pay extra charges for webhosting.
I am not sure, but would like to discuss with someone.
Website URL:
Please enter your website address, or enter n/a if you do not have one.
Facebook Page:
Please enter your Facebook page address if your company has one.
Twitter Username:
Please enter your Twitter Name if your company has one.
Linked In
Please enter your Linked In address if your company has one.
Other Social Media Platforms
Please tell us about any other social media platforms you utilise.
Social Media Assistant:
Here at the EIC we offer a social media assistant package to enable you to harness social media without the hassle of having to manually do this, please indicate if you are interested in this service.
Yes - I would like to discuss further
No- I would not use this service
Not sure, I would like to talk to someone about this
Out Of Hours Access:
The EIC operates between 08:30 - 17:00 Monday to Friday, if you would like 24/7 access to the centre, which would enable you to utilise the hot desks / printers / internet at different times please select YES, NB: There is a £5.00 one off charge for this.
Yes, I understand that an additional £5 one-off charge will be applied
No, I do not need 24/7 access
Multi Function Printer:
At the EIC we have a number of MFP's which include Fax machine, copier& scanners. These are costed at 8ppp B&W and Fax per sheet, 9ppp for colour, which is applied to your monthly invoice. Please indicate if you like an MFP code.
Yes
No
Invoice preference type:
In order for us to commit to having a paperless office, please indicate how you would like to be invoiced.
Electronic Paperless (FREE)
Traditional Paper (£1 per invoice)
Proof of I.D:
In order for legal compliance, we are required to confirm your identity, please indicate which document you are able to produce in order to do so.
Passport
Drivers Licence
Identity Card (national)
Proof of address:
Please indicate which document you are able to produce in order to confirm your ID, documents must be less than 3 months old.
Bank Statement
V5 Vehicle Document
Utility Bill
Polling card
AntiSpam: 10+32 =
Please enter the sum total.
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