Landline Telephone and Broadband Application

Sunday, October 21, 2018 - 22:11

Customer Information

First Name *

Middle Initial

Last Name *

Contact Number * 592-

Date of Birth *

Month

Day

Year

Passport/ID # *

ID Card *

Upload an image of your ID Card
Files must be less than 10 MB.
Allowed file types: gif jpg jpeg png pdf.

Proof of Address *

Recent (< 6 months) bank statement or utility bill
Files must be less than 10 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Additional Document

Upload any additional document that may be relevant.
Files must be less than 10 MB.
Allowed file types: gif jpg jpeg png.

Service Address *

Email Address *

Confirm Email *

Billing Address

Enter billing address if different from service address

Nearest Telephone #

Place of Employment *

Position *

Telephone # *

Is your lot

lot info 1 *

Single

Double

lot info 2 *

Own

Rent

Years There *

If property is a double lot indicate which point same is situated: *

Eastern

Western

Northern

Southern

Property has more than one lot *

Yes

No

If yes, choose an option

First

Second

Third

Fourth

Is this a business application? *

Yes

No

Name of Business

Type of Business

Do you require DSL?

Yes

No

Are you the legal renter of the line? *

Yes

No

If no, kindly submit authority to use landline or effect temporary name change.

If yes please complete the following for your DSL application

Please contact a service representation or call 0488 for more details on Broadband availability.

Service Options (Residential)

Plan

Gold

Silver

Bronze

Speed

Up to 10 MPS
Up to 5 MPS
Up to 1.5 MPS

Rental

$9,999
$8,999
$6,299

Optional

Fixed IP address, $5,000

Have you or any other member of your household had telephone service before? *

Yes

No

If yes, contact:

Other persons authorized to make changes (name in full):

Location:

Telephone #:

Please click here to read terms and conditions.

terms and conditions *

I agree to the terms & conditions.

Internal Use Only

CSR's Name

Store Location