iSage Customer Application Form

	CUSTOMER MODIFICATION
	iSage.aunz.net ABN 90 297 906 349 - ACN 133 451 224 349 Postal Address: PO Box 385, Paradise Point QLD 4216 Tel 1300 725 789 - Fax (07) 5547 5000 - Web www.isage.aunz.net

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:

OR Company Name:

ABN:

Billing Address:

Town/Suburb:

Postcode:

Customer No .:

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.aunz.net 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.isage.aunz.net 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 iSage. 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 iSage Internet to change my pre-select telephone carrier to iSage 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 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 www.isage.aunz.net

Area Code	Telephone Number	Area Code	Telephone Number
1.		4.
2.		5.

Estimated value of calls per month: $

Current Provider:

AND/OR I wish to order:

NEW line installation

EXTRA line/s at same time

Line RE-ACTIVATION

Total required:

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 www.isage.aunz.net, 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: