APPLICATION FOR SERVICES AND PRODUCTS WITH iZIP
20 Station Road
NUNDAH  Q  4012
   

Phone: 07 3266 6500
Email: sales@izip.com.au
ABN: 78 710 747 365
Internet & IT Services for Australia
SERVICES Please select the service(s) you wish to apply for
  BROADBAND ADSL     DIALUP     WEB HOSTING     PRODUCTS
  256 / 64     Light     Light     Essential  
iZIP 256 Micro iZIP Ultra Light Basic_5 iZIP One Page Contact  
  iZIP 256 Min         iZIP Medium         iZIP @ Light         iZIP iPOC System  
      iZIP 256 Max     Heavy     Heavy     Professional  
  512 / 128         iZIP Heavy         iZIP @ Plus         iZIP One Page Ordering System  
      iZIP 512 Min         iZIP 18-6         iZIP @ Ultra         iZIP Task Guide  
      iZIP 512 Mid         iZIP Freerange         iZIP @ Premium         iZIP Online Shop  
      iZIP 512 Min     Pre-Paid     Standard     Custom  
  1500 / 256         iZIP Pre-Paid         iZIP @ Standard         Please provide details in 'Other' below  
      iZIP 1500 Min                                      
      iZIP 1500 Max                                      
Please provide additional details or info including that of the domain name you own or wish to order (if applicable)
Other  
Please Specify:
       
       
Please view the www.izip.com.au website for full pricing and for terms and conditions
   
PERSONAL AND / OR BUSINESS DETAILS Please provide accurate details
Full Name:   Date of Birth:
Business Name:  ABN (if business):
Billing Address: 
Suburb or Town:   State:  Post Code:
Home Ph:  Work Ph:  Mobile: 
Email Address: (for billing and for information / notices)  
   
Preferred Payment Method
Direct Debit (Bank Account) (please also submit the ezidebit application form from www.izip.com.au/ed.pdf)  
  Direct Debit (Credit or Debit Card)     (please also submit the ezidebit application form from www.izip.com.au/ed.pdf)  
  Direct Deposit (Bank Transfer)     upon approval only  
    Cash, Cheque, Money Order or Other     upon approval only  
   
ADSL Service Details This section only applies if you wish to order an ADSL service
I wish to: Churn (transfer) my current ADSL service to iZIP Maintain my existing iZIP ADSL service
Provision a new service with iZIP (I don't currently have ADSL) Relocate my iZIP ADSL service (fees apply)
ADSL Phone Number:(incl area code)   Current Provider (if churning service): 
ADSL Address (physical Address of ADSL phone number): 
 State:  Postcode:
AGREEMENT AND AUTHORITY
  •  
    		•  I hereby declare that I have the authority to authorise any changes and or orders and that the details I have provided are true and correct.
  •  
    		•  I hereby request that iZIP be made my selected carrier / provider for ADSL, webhosting or dialup and for iZIP to use the carrier or provider of their choice for my services for the duration of any applicable contracts and beyond or until further notice in writing signed by myself which has been acknowledged as received by iZIP if there are no applicable contracts.
  •  
    		•  I authorise iZIP in full to sign any additional documents on my behalf, to give effect to and maintain these changes now and in the future and to retain my services with iZIP under any circumstances and I further acknowledge that on occasions this may incur fees.
  •  
    		•  I agree to abide by the Terms & Conditions of service and Service Rates published on the www.izip.com.au website.
  •  
    		•  I am not under any contract with another provider and I will inform iZIP in writing of any changes to my details or circumstances.
  •  
    		•  I personally will bare any and all responsibility for payment and use and or missuse of this service on behalf of the business.
  •  
    		•  I confirm that I am over 18 years of age and I am authorised to enter into this agreement with iZIP
    Applicant Signature:   Date: 
    Print Name:   Title or Position : 
    This document is copyright © 2006 iZIP