Veetel :: ADSL FORM

ADSL 2

*Account Details

Title :

First Name :

Last Name :

*Address

Unit or Level :

Street Number :

Street Name :

Suburb/Town :

Postcode :

State :

If your billing address is different please tick the box

* Date of Birth :

Drivers Licence Number :

Expiry Date :

*Service Details

Please provide the telephone number/s you would like to apply for VeeTel ADSL 2 & Line Rental Bundle Plan

1st Phone Number :

2nd Phone Number :

3rd Phone Number :

4th Phone Number :

Current Line Rental Provider :

If other please specify :

Please Select your ADSL 2 Plan

Bundled Plans With Standard Line Rental :

Stand Alone Plans :

Free connection on a 24 Month Commitment
No contract (A $99 Connection/Transfer fee will be charged on your Bill)

Select your desired username and password :
Username :
	@veetel.net.au
Alternate Username :
	@veetel.net.au
Password :
	(Minimum 6 characters)
Confirm Password :

* Please provide at least one contact number :

Contact Mobile Number:

Contact Phone Number :

Contact Work Number :

Email-Address :

How did you here about us :

Word of mouth

Radio

Newspaper

Other(Please specify) :

Referee's Name :

Referee's Telephone Number :

Comments :

Terms and Conditions :

By registering for ADSL 2 plan.

I am authorizing VeeTel to transfer my existing ADSL connection from my previous provider to VeeTel as stated in this application form. I am also authorizing VeeTel to transfer my Line Rental from my previous provider to VeeTel. I understand that if I do not have an existing Telephone line, VeeTel can arrange a new line at my premises with further connection fees applicable. I have also read and understood the Full Terms and conditions listed under terms and conditions on this website: http://www.veetel.com.au/page.aspx?pid=4 I am aware of all fees involved and happy to proceed with the plan I have selected on this application form.

I have read and agree with all the terms and conditions