Customer Authority: DSL Application

1. Application for DSL service
By completing and signing this form, you are agreeing to implement a new DSL service to the premises on this form.

2. Your Details
Title: ____ First Name: _______________________ Surname: ________________________________ Company Name: ____________________________ (if applicable) ABN: ________________________

Address of DSL service to be supplied:
Title: ____ First Name: _______________________ Surname: ________________________________ Company Name: ____________________________ (if applicable) ABN: ________________________ Unit Number: _____ Street Number: ______ Street Name: ____________________________________ Suburb: ________________________________________ State: _______ Postcode: _________ Billing Address (if different to the above address) ___________________________________________________________________________________ Suburb: ________________________________________ State: _______ Postcode: _________

Phone number at the site for the DSL service you wish to have:
(Please note that we will provision a new line at the premises for the purposes of carrying the DSL only. The Telephony component of this service will not be active, since there will be telephony features on the DSL.) The below is for us to confirm the address and make installation of the new line easier.

Area Code

PSTN number on site (used for checking purposes only.)

Site contact Name

Site contact Phone Number

Please select one from below only (tick) PSTN line VoIP Tail only VoIP tail with Data Speed 256/256kbps 2Mb 4Mb 24Mb
Note: ADSL2+ is subject to availability and distance from exchange.

you need to be aware that all internal wiring must be in place and in working order prior to the virion Contracted Technician attending. Agreement Your Signature: ________________________________________________________________________ Today’s Date: ____/_____/____________ Day time contact number: ______________________________ Please fax your completed form to (02) 8212 8038 or email a scanned copy to sales@virion. and with full throttle 20+MB Internet speed an extra $90 per month. Line Hunt. • The information provided in this form is true and correct. The term of the agreement is for 12 months. Due to infrastructure limitations in some areas with exchange and • You have read and understood the terms of this application 5. You realise that there will generally be no Telephony Component to the Unbundled Local Loop line which we bring in for this ADSL2+ service. For ongoing technical support for your DSL modem contact your onsite consultant. Terms of this application: • We will supply your DSL service from the date the installation takes effect and notify you when that happens) and you are responsible for the payment of all charges associated with the service from the date this successful application takes effect. You agree to waive the Customer Service Guarantee which states that we install the service within 5 days of application. The standard cost of the service is $69 per month for the VoIP tail only. We are obliged to offer you something since this cannot be met. You must also ensure that you are present during the agreed appointment with 4MB Internet an extra $50 per month. There are no Value Added Services on this ULL line such as Call Forward. you agree as follows: • You are the account holder of the PSTN phone line service(s) listed above. Modem devices are not supplied as standard and this will need to be discussed with your onsite consultant. Other Information • • • • You can contact virion by phoning 02 9971 8000 if you have any questions or issues about this application or send an email to support@virion. distance from the exchange and other limitations beyond our control there is no guarantee that the service will be able to be implemented. CLI blocking. There must be a complete circuit from the premises to the MDF for the technician to connect to. and this will be a static IP address. Our Suppliers You consent to us providing your personal information to our suppliers for the purpose of providing you with the We may refuse or cancel your service on the basis of our credit assessment of you. however we will be transparent about the application. If you require cabling we can arrange contractors to cable from MDF through to your office socket for an extra charge. Since the service will typically be installed 14-21 days after application. The cost of the service of the VoIP tail with 2MB Internet data speed incurs an extra $30 per month (inc GST). White pages listing. You acknowledge that we depend on other suppliers to provide the DSL service and our ability to provide the DSL service to you may be affected by other suppliers. We can provide a modem if needed – quote and specs will be provided on application Your information will be kept private and confidential 7. Please ensure that for MDU (greater than 3 floors or 10 unit dwellings with multiple offices) installations. 6. etc. line rental for a PSTN line is $30 per month (inc GST). this effectively must be waived. or are authorised by the account holder to authorise this service application.3. The Contracted Technician will only jumper the service from the A side to the B side of the MDF and not connect any wiring considered CPE such as IDFs or wall sockets. . You understand that we do not provide email or web hosting services on these ADSL2+ tails. Voicemail. silent number. • • • • • • • • • • • 4. We will notify you that the provision of your DSL service has been completed within 10 working days of the transfer taking place. Installation fee is $99 in GST. Your Agreement By signing this form. which is beyond our