iSage Telstra ADSL2 Application Form
PO Box 385, Paradise Point QLD 4216
Phone: 1300 725 789 - Fax: 07 5547 5000 - Email:
Web: - ABN 69 621 500 909 - ACN 621 500 909
1. Customer Details
Full Name:  Date of Birth: 
OR Company Name:   ABN: 
Billing Address: 
Town/Suburb:   State:   Postcode:   Account/Order No.: 
Home Ph:   Work Ph:   Mobile: 
Email Address:   (for Accounts notices)  Driving License: 
Secret Question:   Secret Answer: 
How did you hear about us?  Web Site Friend TVYahoo Radio Brochure  Promotional Code: 
2. Next of Kin Details
Next of Kin:  Relationship: 
Town/Suburb:   State:   Postcode: 
Home Ph:   Work Ph:   Mobile: 
3. Payment Method
Monthly payment by: VISA MasterCard Cheque Direct Deposit Money Order
Card Number:       Expiry Date: 
Cardholder Signature:     Date:   
Please note your signature constitutes sufficient authority for to or its nominee to initiate a transaction every month with the above Credit Card account for payment of any monies outstanding and due by you.
4. ADSL2 Service Details
Refer for current plan rates
$50 Security Deposit, $99 ADSL2 Activation, $30 Transfer / Upgrade Fee, $99 Disconnection under 6 months
Plan or Package Name:  -  Monthly Fee: $
Preferred Username: 
ADSL2 Order Type: New Service Transfer Service
Modem ($15 postage)  BYO Modem Modem:
Security Software Internet Security Suite $4.95 p/m    
ADSL Phone Number (with area code):   Current Provider: 
ADSL Site Address: 
Town/Suburb:   State:   Postcode: 
5. Phone Service Details
Complete this section ONLY if bundling phones
I certify that I am the telephone account holder or an authorised representative of the account holder. I authorise iSage Internet to change my pre-select telephone carrier to iSage Internet for Local Calls, National Long Distance Calls, International Calls, calls to Mobiles, ADSL2, Line Rentals and handsets (if in place) and any other pre-selectable services currently charged to the telephone service numbers I have nominated below. I am aware that iSage Internet will begin charging me once the line has been pre-selected and I accept the current rates and charges for my pre-selected telephone services as published at
  Area Code    Telephone Number   Phone Services (please specify e.g. Silent Number)
Estimated value of calls per month: $   Current Provider: 
Order Type: New Line Installation  Line Transfer  Extra Line Installation  Line Re-Activation  
6. Customer Agreement
By signing this form I am stating that I have read and agreed to the iSage Internet Terms & Conditions as published at, and that all the details I have provided here are correct. I authorise iSage Internet to perform any necessary credit checks to support this application under Section 18(E)(1) (Privacy Act 1988). I am not under any contract with another provider and I will inform iSage Internet in writing of any changes to my details. I confirm I am 18 years of age or older and am authorised to enter into this agreement.
Signature:   Date: 
Print Name:   Title/Position: