Change of Address Form

AuNix Change of Address 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:

Account Number:

2. Current Service Details

Please tick any of the appropriate service/s that you wish to reloacte.
ADSL / 2 Service - Username:
Voice Service - Number:

3. New Details

Full Name:

Date of Birth:

Company Name:

ABN:

Billing Address:

Town/Suburb:

State:

Postcode:

Home Ph:

Work Ph:

Mobile:

Email Address:

(for Accounts notices)

4. Payment Details

(Only fill in this section if updating billing details)

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 iSage Internet 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.

5. New Service Address Details

Service No (if not bundled):

Package Name:

Service Address:

Town/Suburb:

State:

Postcode:

The details above will be used to relocate your AuNix service/s. New installation fees are applicable to connect your service/s to your new address. Disconnection fees may apply if your previous address has been active less than the contract period.

6. 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 AuNix Internet to perform any necessary credit checks to support this application. I am not under any contract with another provider and I will inform AuNix 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: