AuNix ADSL2 Application Form
PO Box 887, Oxenford QLD 4210
Phone: 1300 765 742 - Fax: 07 5547 5000 - Email: info@aunix.com.au
Web: www.aunix.com.au - ABN: 90 297 906 349
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)  Promotional Code: 
How did you hear about us?  Web Site Friend TVYahoo Radio Brochure
2. Payment Method
Monthly payment by: VISA MasterCard
Card Number:       Expiry Date: 
Cardholder Signature:     Date:   
  • I authorise iSage Internet to debit this credit card for my setup and ongoing service charges.
  • I also authorise this credit card to be used to pay my account if my DD method of payment is not received by the due date.
Direct Deposit : Requires the credit card provided above for the first payment and if payment is not received by the due date. box
3. ADSL2 Service Details
Refer www.aunix.com.au 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:
Cost:
ADSL2 Phone Number (with area code):   Current Provider: 
ADSL2 Site Address: 
Town/Suburb:   State:   Postcode: 
* For month to month contracts: $99 Disconnection Fee if relocating or removing ADSL within first Six months.
For 12,18 or 24 months contracts: Early Termination Fee of $198 within first 6 months or $99 after 6 and before end of contract.
4. 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 AuNix Internet to change my pre-select telephone carrier to AuNix 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 AuNix 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 www.aunix.com.au
  Area Code    Telephone Number   Phone Services (please specify e.g. Silent Number)
1.    
2.    
Estimated value of calls per month: $   Current Provider: 
Order Type: New Line Installation  Line Transfer  Extra Line Installation  Line Re-Activation  
5. Customer Agreement
By signing this form I am stating that I have read and agreed to the AuNix Internet Terms & Conditions as published at www.aunix.com.au, 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. 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: