AuNix Customer Modification Form

Customer Modification 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. Modification Type

Modification Type :	Credit Card / Billing Details	Change Plan or Package
	(Please complete section 2, 3 and section 6)	(Please complete section 2, 4 and section 6)
	(Please complete section 2, 3 and section 6)	(Please complete section 2, 4 and section 6)

2. Customer 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)

3. Credit Card Details

Monthly payment by:

VISA

MasterCard

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.

4. Change of Package

Refer www.aunix.com.au for current plan rates

Current Plan or Package

Plan or Package Name:

Monthly Fee: $

Username:

ADSL Phone Number (with area code)

New Plan or Package

Plan or Package Name:

Monthly Fee: $

Please note that if you are changing ADSL line speed a charge of $30 will be incured. You new plan will not be implemented until the start or your next billing cycle unless otherwise arranged by AuNix. If choosing a plan that involves the bundling of you phone line please fill in section 5. Authority to Pre-Select.

5. Authority to Pre-Select

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, xDSL, 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

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: