Teleus Pty Limited

Network Service Application

CUSTOMER INFORMATION

Planname
National Plus
ABN/ACN *
Trading As (if applicable) *
Years Trading
Contact Name *
Position
Employer
Date of Birth *
Drivers Licence No
Telephone *
Mobile *
Facsimile
Website
Street Address *
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
System Maintainer
Contact Name
Telephone
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 TELEUS 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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