Network Service Application

Planname: Local Plus

CUSTOMER INFORMATION
Trading As (If Applicable) Years Trading
Contact Name* Position
Date of Birth* Drivers Licence No Employer
Telephone* Facsimile Mobile*
Website
State Postcode
 
Previous Street Address (If at above address for less than 2 years)
     
State Postcode
       
Postal Address (If different to above)
     
 
Customer System & Other Details
ISDN number ranges (Please Specify)
ISDN prime number of the range (Please Specify)
System Brand System Model Telephone
System Maintainer Contact Name
System Reprogramming Required*
Yes No
           
Service Options (Full Service)
Service Information (Complete Supplementary Line Application Form if further space required)
I elect to have the telephone numbers in this section tagged as (Please tick one)
Listed or Unlisted
Line No Name Description
Privacy Statement

If you are an individual we will collect personal information about you. Clause 7 of the Standard Customer Agreement contain provisions about the use by Bolotelecom of your personal information. A summary of clause 7 of the Standard Customer Agreement is set out in the Summary provided with this Application. You should also read the provisions in the Standard Customer Agreement. By signing this Application you confirm that you have read and understood and you agree to those provisions.

If you would prefer that we do not use your personal information for direct marketing purposes, please tick this box (see clause 7.2(e) of the Standard Customer Agreement, a summary of which is set out in the Summary provided with this Application, for the way in which we will use your personal information if you do not tick this box).

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Phone: 1300 939 717 | Fax : 1300 368 880 | Email: info@teleus.com.au