Astron Communication and Information Services Pty Ltd

Long Talk Plan - Application Form

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

Your Details			Your Address
Company Name:
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 :

How long have you been at this address : months years
Rent Own

Telephone Services : Is the telephone in your name ? Yes No
Current Carrier Telstra Optus AAPTPrimus Other

Override Service you are using ? 1414 1428

Do you authorise Astron to shift your override code services from present company to Astron ?
Yes No

	Long Talk
Phone number(s) :	Override Direct
Phone No. 1	Yes Yes
Phone No. 2	Yes Yes

Internet Services
Yes No Username Password

Acknowledgement:

I acknowledge that Astron will bill me for National and International long distance calls, calls to mobile phones(if applicable), and local calls and Internet service Access (if applicable) from the line(s) listed above for the service(s) I have requested.
1. Astron will provide me with Services subject to its Terms and Conditions which have been supplied to me.
2. I certify that I have the authority to make this change and that these details are correct.
3. 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. 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.

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.