Aussie Phone Brokers

Transcription

1 iinet FORM INFORMATION for return to Aussie Phone Brokers Contact: Aussie Phone Brokers Malvern Rd Toorak, 3142

2 iinet Required Information - FOR BUSINESS ACCOUNTS Introduction The iinet applications are all made through an internet portal. During the sign-up of any new client, their information is entered in specified fields. Aussie Phone Brokers Form Structure The online portal is designated in five pages. Aussie will follow the same structure. All required fields will be marked with an asterisk * Aussie can only accept orders with completed forms. Privacy of Information As with any application for service, the information provided is sensitive. Aussie can assure our clients that all information is treated with the utmost care and remains as secure as possible at all times. Notes on Acronyms used ISP = Internet Service Provider ADSL = Type of Internet Connection ADSL2+ = Newer & Faster Internet Connection Availability of Connections Connections for services may not always be available. You can ask Aussie to check for you: on or via What this form is for Please complete all details of this form and fax back to Thank you.

3 PAGE 1 Current ISP (if transferring) Phone Number Service is running through (or will) Preferred Username INTERNET CONNECTION DETAILS PAGE 2 PLAN iinet Plan Name PAGE 3 Do you require New Modem? (Note: ADSL modems will not provide ADSL2+ connection) Tick one box: Other requirements? (e.g. extra splitters) HARDWARE Let Aussie Choose my Modem 1-Port, non-voip modem $64 or $69 4-Port, VoIP modem $230 or $239 4-Port + Wireless, VoIP $269 or $309 The above prices shown are buying from Aussie or $iinet. Also, our modems are a little more configurable that iinet s. (Full-featured modem from Aussie: $269 and Purchase from Aussie Phone Brokers, or Purchase from iinet. No Purchase; I have my own ADSL2+ modem Set-up fee is an additional $79.95

4 PAGE 4 ACCOUNT INFORMATION Salutation First Name Last Name Work Phone Mobile Phone Date of Birth (if possible) Company Name Company ABN Company Fax Street Number for Service Street Name for Service Suburb & Postcode Billing Address Shipping Address Must be manned between 9am & 5pm.

5 PAGE 4 - Continued (Choose One Payment method) 1 - CREDIT CARD PAYMENT DETAILS, OR Creidt Card Type Card Number Expiration Date Name on Card Circle Payment Frequency Monthly -- Quarterly -- Annually 2 - DIRECT DEBIT PAYMENT DETAILS Banking Institution Name on the Account Branch Number (BSB) Account Number Circle Payment Frequency Monthly -- Quarterly -- Annually ID DOCUMENTATION Drivers Licence/ Passport/ CC Place of Issue Name on Document

6 Direct Debit Authority You are entering into an agreement with iinet Ltd APCA user identification number Do you authorise iinet to direct debit money from your account, through the bank's bulk electronic clearing system, when invoices fall due to cover the charges on your account? I agree that iinet can deduct money from that account, on the day my invoice is due as long as I have an iinet account, or; I agree until I withdraw their permission for the direct debit and make another payment arrangement. I am able to operate this nominated account as a sole signatory. I authorise iinet to contact my financial institution to verify my bank account details. I authorise my financial institution to release information allowing iinet to verify my bank account details. I understand that by proceeding now I will be deemed to have signed a direct debit authority. I agree to all conditions listed above as part of the Direct Debit authority. Signed: Dated: I also agree that Aussie Phone Brokers may complete my application with iinet and that it shall be a fully binding contract with iinet, as per the conditions of service and the attached Customer Relationship Agreement. Signed: Dated: [Please ensure you sign both of the above. Thank you.]