ADSL Line Activation Form 

ABN : 59 420 535 102       Business Name : Intertech Country

Telephone :

08 8723 6262

Address : 93 Commercial St, West Mt Gambier, SA 5290 Domain Name: http://www.icisp.net.au

Facsimile :

 08 8723 6263

Terms and Conditions : Please note:To use ADSL you must be within approximately 4 kilometres of the Telephone Exchange.

This Form must be completed for each ADSL Line Activation for each End user.

1.Any relevant charges will be applied to the Customer Account and are payable as per the Payment Terms specified on this Form.
End User Connection -
Full Name of End User : 		 
 Company Name of End User :   
ADSL Line Phone Number :
 

(           )  

End User Site Address :
 (Actual address where the
 telephone line is located)


 

 

 Address :

 

 City :

 

 Postcode:

                      State :     

Username:

   

Password:

 

Drivers licence no:

 

Date of Birth:

 

New Service :      

Existing Service :      

Cancel Service :    

Service Transfer from other Provider :  ( Provider Name:(                                                       ) churning

 $50.50
Cancellation Fee for Existing service contract :

 

   $75.00
Line Speed Change : $50.50

 ***** Line Activation Fee:

Once off fee

 $115.00

***** Activation Fee $115.00 payable upon submission of application form.  (prices as of 1st July 2008 E&OE)
N.B. If you cancel your service during/after activation your $115.00 activation fee is non refundable.
* AUP-Acceptable Use Policy Once the AUP has been reached during a calendar month, the speed may be slowed to 64Kbps/64Kbps.   

 ADSL - buy your modem and pay the Activation fee - min. 6 months (prices shown are per month)
ADSL Circuit (256/64) 200MB * each p/m   Excess data charged @ $0.12 cents per megabyte  
This   plan is not capped

starts at
$33.00
ADSL Circuit (256/64) (Subject to AUP) - 15 Gig * per month  then slowed to 64Kbps  $39.50
ADSL Circuit (512/128) (Subject to AUP) - 20 Gig * per month then slowed to 64Kbps  $49.50
ADSL (1500/256)  (Subject to AUP) - 20 Gig * per month then slowed to 64Kbps  $66.50

 

Required Additional Information

Operating system:

98/me/2000

XP Home / Pro  

Vista h / b / p / u 

 Mac o/s:

Computer type:

Desktop

Laptop

laptop brand:                                 model:

Modem type required:

single port

4 port

wireless

w/network card req.

Wireless network info:
to be provided by Intertech

network name:
 

security key:
 

 Do you have a security alarm system   Do you have Austar connected to your phone line

terms & conditions given to client

SIGNED by ___________________________  Print Full Name________________________________
 
The signatory warrants that it is duly authorised to order these services on behalf of the ("Customer") named in this order. E&OE
** Minimum Contract Term:12 months- Prices do not include set-up fees or cost of ADSL moden and filters. Payment can be made by Credit Card/Cheque/Cash/Direct Deposit/bpay    EXECUTED as an agreement on the ___________ day of________________  200___