Applied VoIP Application Form 1 Company Details Enter your details, before choosing the service(s) you require. Company Details Contact Details Company Name Telephone Number Trading Name(if different) Fax Number Unit / Street Number Accounts Contact Name Street Name Billing email address Suburb Contact email address State Postcode ABN or ACN Number Toshiba Dealer Name 2 Service Requirements Choose the most appropriate level of service you need, enter the quantity you require and add the total amount (in $) in the total box. IncomingOutgoing10 Consecutive DID50 Consecutive DID100 Consecutive DID Cost per Monthex GSTQtyTotal Business 1 DID $15.00 Business 10 DID $27.50 Business 50 DID $105.00 Business 100 DID $155.00 Static IP Address (required for business 10, 50 or 100 DID's) 3 ADSL2+ Applied VOIP Voice only SIP trunk Service Please select the ADSL service if required please Click to order this service or continue if not required TypeContract PeriodInstallation FeeMonthly CostTotal minimum cost forcontract periodOrder ADSL2+ (20Mbs/1Mbs) 12 Months $125.00 $75.00 $1,025.00 Phone number for ADSL service to be provisioned on. A personal guarantee is required for all ADSL orders. Download it here and fax it to us on 02 9980 8269. 4 Porting Requirements If you are porting your existing number(s) to us, please Click to order this service or continue if not required Type of linePorting Charge + GSTPrice per Rejection + GSTEmergency Returns + GST CAT A (Single number simple) * $120.00 $60.00 $60.00 CAT C (Complex 1-5 numbers) ** $420.00 $150.00 $525.00 CAT C (Complex 6-20 numbers) ** $600.00 $225.00 $1650.00 CAT C (Complex 21-100 numbers) ** $720.00 $270.00 $4800.00 CAT C (Complex 101-200 numbers) ** $1080.00 $420.00 $7200.00 The porting charges are a one-off cost. If, however, the ported numbers are taken in addition to your monthly service plan a monthly fee will apply. Please contact us for pricing details.Emergency returns are charged if the porting has to be cancelled at the last minute and put back to the original configuration.* This applies to a single phone number without any additional services like line hunt, diversion, call waiting etc.** This applies to a line with additional services either a PSTN, BRI or PRI connection eg GDN, DID, MSN etc Telephone NumberCat A/CCurrent CarrierCurrent Carrier's account number OR I wish to port a range of numbers First number in range Last number in range Current carrier Current carrier's account number Preferred cutover date (dd/mm/yyyy) Preferred cutover time Account Details ( exactly as they appear on your most recent phone bill)Account Holder Details Business Name Surname Unit Number Given Name(s) Street Number Street Name Suburb State Postcode 5 Check and submit your details To help us to reduce spam email, please enter the code and submit the form and we will be in touch. Neither myself or any of the directors of the company have filed for bankruptcy or insolvency in the last 10 years * No company under my or my fellow directors ownership/control been placed into receivership/liquidation in the past 10 years * I certify that I am authorised to sign this order form and associated documentation on behalf of the applicant and the information given is true to the best of my knowledge. I agree to comply with Applied VoIP PTY LTD conditions. * I have read and I agree to the Terms and conditions * Name Position Date To keep a copy for your own records click the print form button To reduce spam email, please enter the anti-spam code before sending. Please enter code below: Please check your details and send the form ( * required fields )
