Astron Communication and Information Services Pty Ltd

Best Rates Combo - Application Form

This form must be signed by the Telstra account holder in your household.

Your Details			Your Address
Title:			Flat/Unit No:
First Name :			House No:
Middle Name:			Street Name :
Surname:			Suburb :
Date Of Birth:			State :
Home Phone:			Post Code :
Mobile Phone:			Email :
Work Phone:			ABN No. :
ID Type :			ID Number :
Other :			Expiry Date :
Employer Name :			Occupation :

Telephone Number ADSL is to be Connected to

Do you have ADSL service for this number? Yes No
Please ensure that the number the ADSL service is to be connected to belongs to the Telstra Network and does not have any services on it such as call divert, call waiting etc.

Telephone Service

Is the telephone in your name ? Yes No (AstronComboPlus not available to Optus and Primus customers)

Phone Number
	Area Code	Phone Number

	Contract Term
ADSL Speed :	Contract Term
ADSL Speed :	24 months - Free Set Up
Download Limit :	12 months - $90 Set Up Fee
Monthly Fee :	No Contract - $180 Set Up Fee

Full Services (Telstra Customer Only)	Switch from your current company to Astron	Phone Line Connection (Socket Exists) $59
Full Services (Telstra Customer Only)	Connection with a technicians visit $125	New Phone line request $299

Acknowledgement:

I certify that the telephone number is registered in my name and I have the authority to make this change/transfer. Astron will bill me for calls made from my telephone lines or services, if applicable, in accordance with Astron's current prices. The service will be provided subject to the provisions of Astron's terms and conditions. ASTRON, credit providers and the Carrier(s) may exchange call charging and company account information. If applicable, I authorise Astron to charge my credit card for all amounts owed to Astron when those amounts become overdue and which I have not disputed by giving Astron written notification of the dispute.
I authorise Astron to make arrangements with my current telephone company for the transfer of lessee of my lines and accounts to Astron. I understand I will still be responsible to my current telephone company for any charges which are incurred and billed up to the date the transfer is effective. I acknowledge that I may surrender all incentives and benefits with my current telephone company. The telephone service number(s) will be transferred with their current status. I will contact my current telephone company in relation to providing services and any faults until the transfer is effective. I certify that nobody in my household requires priority or emergency services from Telstra for health or medical reason or suffers from a medical condition which may require emergency service, as Astron cannot provide such service.

I hereby authorize payment by my credit card below for the set up fee($90/$180, “tick” where applicable) and delivery charges ($12.50) for my ADSL service under the Combo Plus III line rental plan:

Credit Card Type :

Visa Master Diner Amex Bank Card

Card Holder's Name :

Card No. :

Expiry Date :

I accept the Terms and Conditions of Astron.