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APPLICATION form

 

User Information

Your full Name *:
Email Address * :
Date of birth *:
Drivers license# / Medicare# *:

 

Street Details

Address/Street:
Address/Street:
City/Suburb *:
Postcode *:

Billing Details

Address/Street:
Postcode:
City/Suburb:

Last monthly bill

Services


Telephone numbers to connect (include area code) if you put a mobile number here we will contact you regarding getting a new sim card to you.

Telephone number #1:
Telephone number #2:
Telephone number #3:

Recommended by

Please put the persons telephone number or name:

Current Carrier (eg Telstra, Optus etc)

Current local call carrier::
Current long distance carrier:

Service Type (not including mobiles)

 Pre-selected only for national, international calls & calls to mobile. You will not be billed for line rental

 A full service customer for all local, national, international & calls to mobile and line rental

 Please provide me information about an internet connection & a consultant to contact me about special deals that you may have

E-mail communication

Do you authorise us to contact you by email?
Yes No

Acceptance of our Terms

 Checking this box indicates that You have read and understand the Terms and conditions set out in the terms and condition page.

Type :

 


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