Astron Communication and Information Services Pty Ltd

Application Form

This form must be completed by the telephone account holder of your household.
Your Details			Your Address
Company Name :			ABN No:
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:
ID Type			ID Number
If Other, ID type:

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

Name of current line rental company

If currently with Telstra for line rental,your Account Number

Phone number(s) :	Combo Combo International
	Yes Yes, use 1428 for International calls
	Yes Yes, use 1428 for International calls
	You agreed to switch to Astron’s 1428 if you are currently using 1428 through another company

24 month contract: Free modem $49.50 set up fee $17.50 Delivery Charge

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

Most frequently called countries 1. 2. 3.

Acknowledgement:

I acknowledge that Astron will bill me for call types as confirmed above for the service(s) I have requested.

Astron will provide me with Services subject to its Terms and Conditions.
I certify that I have the authority to make this change and that the details provided are correct.
In selecting Astron over-ride code service (if applicable), I authorise Astron to cancel service with any current service provider using the same over-ride code as Astron.

Full Service Transfer authorization if applicable:

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.

Our customer service staff will contact you for the required payment for the modem ($100), filter ($10.50), connection fee ($49/$99, “tick” where applicable) and delivery charges ($12.50) for my broadband service under the AstronCombo line rental plan

I accept the Terms and Conditions of Astron.