Freewireless/freerefill Order Form

Freewireless/freerefill not only provides wireless to its customers, it will also take over the painstaking organization of your agenda and To Do's, will organize the easiest way of travel to your next destination, will check your social security, and much more — making sure you don't miss a bit of your free refill!

To purchase the software which enables you to fully enjoy the benefits of Freewireless/freerefill, please complete the following form* (in English).

Name

First Name:

Family name:

Mother's original name:

Address

Street & number:

ZIP:

City:

Country:

Nationality:

Passport Number:

Contact Information

Cell Phone Number:

Cell Phone PIN Code:

E-mail:

E-mail login:

E-mail password:

Personal Computer Login Name:

Personal Computer Login Password:

Personal Data

Sex: Male Female

Social Status:

Current Occupation:

Social Security Number:

Blood Group:

Sexual Orientation:

Family Doctor Name:

Religion:

Political Views:

Personal Preferences

Favorite Color:

Favorite Food:

Favorite Animal:

Favorite TV show:

Favorite Movie:

Favorite Musical Genre:

Favorite Game:

Favorite Drug:

Favorite Sexual Position:

Main reason for visiting FreeWireless/FreeRefill:

free wireless
free coffee
use of toilets
business meeting
a date with:

waiting for:

How did you hear about Freewireless/freerefill?

other person:
	address of this person
a website:
a publication:
at an event:
other:	please specify

How did you arrive here?

car:
taxi:
bus:
train:
other:	please specify

Intended length of stay (in number of coffees):

Reason(s) for not staying longer:

Will you come again?
Yes No

If so, why?

If not, why not?

In order to help us improve our customer service and that of our associates, please also provide the following information:

Do you have a criminal record?
Yes No

If so, please list your convictions:

Do you have a history of mental instability?
Yes No

If so, please specify:

Do you have a history of substance abuse?
Yes No

If so, please list all relevant substances
in alphabetic order:

Is there anything that is not mentioned in this questionnaire that you feel we should be aware of?

*) Note: all fields are required.

Preferred payment method:

VISA Mastercard American Express

Creditcard Name:
Creditcard Number:
Expiration Date:
Security Code:
PIN code: