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AuNix Telstra ADSL2 Application Form
AuNix ADSL2 Application Form
PO Box 887, Oxenford QLD 4210
Phone: 1300 765 742 - Fax: 07 5547 5000 - Email:
Web: - 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 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:
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
  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  
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, 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: