9121175_3 Updated: 1 January 2008
ISDN 10/20/30 Application Form
Send a signed and completed copy to your Telstra Representative, or send a scanned, signed
and completed copy of the form to dealercare@team.telstra.com.
Company Name is the legal
entity under which the service
will be registered. In this
Application Form, references
to "you", "I" or “us” refer to the
Company.
ACN / ABN is Australian
Company Number or
Australian Business Number.
Trading / Business Name is
not a legal entity but is the
name under which your
business trades.
Contact Name is the person
representing the Customer for
billing and contract
administration.
Technical Contact Name is
the person representing the
Customer who is responsible
for the technical aspects of the
service, that is, your
authorised representative for
the service.
You must notify Telstra of any
changes to your Contact
Details.
Company Name
ACN or ABN
Registered Address
Trading / Business Name
Contact Details
Contact Name
Contact Details
Ph (wk):
Ph (mb):
Fax:
Email:
Technical Contact Details
Contact Name
Contact Details
Ph (wk):
Ph (mb):
Fax:
Email:
On Site Contact Details
Address where the service
will be connected
Name of an on-site contact
Phone No. of on-site contact
BUILDING DETAILS
Is the building owned or
leased?
Leased Owned
If leased, Building
Owner/agent:
Name:
Phone No:
Is the building existing or
under construction?
Existing Under construction
Is lead-in required?
Yes No
If yes, please specify details in Additional Customer
Information section.
What type of building is it?
Residential Commercial
Is the building multi-storey?
Yes No
Telstra Corporation Limited
ABN 33 051 775 556
Page 2
Dealer Name
Dealer Code
Representative Name
Contact Details
Ph (wk):
Ph (mob):
Fax:
Email:
Service Charges
The fees and charges for your
selected ISDN service are the
applicable fees and charges
set out in Our Customer
Terms, in addition to the
maintenance fee.
Maintenance fee
In the event that Telstra is
requested to attend the
Customer’s site to attend to a
fault condition subsequently
proven to be in the Customer’s
equipment, an incorrect call
out charge will apply. The
maintenance fee is set out in
Our Customer Terms.
I am applying for a (please tick one):
ISDN 10 service
ISDN 20 service
ISDN 30 service
ISDN 30 Xpress plan for destination numbers:
________________________________
________________________________
________________________________
I require a (please tick one):
new service
new service using existing/reserved number range:
Specify ISDN 30 number range: ___________________________________
___________________________________
___________________________________
new service using ported number range:
Specify directory number: _______________________________________
Specify porting number range: ____________________________________
Specify current carrier: __________________________________________
modification of an existing service:
Specify ISDN service to be modified: _____________________________
Migration from: ______________________________________________
I require the following number of channels:
Incoming:
Outgoing:
Bothway:
Telstra Corporation Limited
ABN 33 051 775 556
Page 3
Please indicate whether you
require a new Telstra Account
or have an existing Telstra
Account.
If you have an existing Telstra
Account, you may include a
Billing Reference ID. This
should be 16 alphanumeric
characters in length and will
identify bills for your service if
the same Account No. is used
for multiple services.
New Account OR Bill Services to existing Account
For New Accounts, please specify the address you want your bill sent to and bill frequency:
Billing Address
Bill Frequency
Monthly Quarterly
If you have an existing Telstra Account, please specify your Account / Full National Number
(FNN), Billing Reference ID and Billing Aggregator No (if applicable):
Existing Account No. / FNN
Billing Reference ID
Billing Aggregator No.
Please indicate if you require
the enhanced Telstra
Provisioning Commitment
offering. The fee for this
service is 60% of the
installation charge. Full
details of this service are set
out in Our Customer Terms.
If this option is not required,
your service will be installed
according to our Standard
Provisioning Time set out in
Our Customer Terms.
Any installation is dependant
on whether infrastructure is
available.
Do you require an Enhanced
Provisioning time for
installation of your service?
Yes No
If yes:
(requests where infrastructure
is available)
Metro Area within 5 8 working days from the date a
full and complete application form is received by Telst ra
Non-Metro Area within 13 18 days from the date a full
and complete application form is received by Telstra
Please see your Sales
Representative about how to
fill out this part of the form.
Call barring?
Yes No
Calling Line Identification
Restriction?
Yes No
Calling Line Identification
Presentation?
Yes No
ISDN 10/20/30 Business Line
Complete?
Local Voice Calls Timed Calls
Dual Node?
Yes No
Diverse Access?
Yes No
Do you require a directory
listing for this service?
Yes No
If yes, the numbers I wish to list are:
____________________________________________
____________________________________________
Suppressed Address: Yes No
Telstra Corporation Limited
ABN 33 051 775 556
Page 4
Service to be installed at
customer’s rack in Telstra co-
location centre?
Yes No
If yes:
Exchange:
Floor:
Row:
Rack:
Enhanced Service
Assurance?
Yes No
If yes, please contact your Sales Representative for
confirmation of extra charges and coverage options.
Extension Level Billing?
Yes No
Malicious Call ID?
Yes No
User to User Messaging?
Yes No
If yes: Messaging 1 (during set up)
Messaging 3 (during call)
Advice of Charge?
Yes No
Type: During Call End of Call Per Call Request
Operator Connect Diversion?
Yes No
If yes, the number to divert to is .
Customer-Activated
Redirection?
Customer activated: Yes No
Type: Fixed Variable
If fixed, the numbers to redirect to are:
Immediate:
Busy / No answer:
Telstra-Activated
Redirection?
Telstra-activated: Yes No
If yes, the numbers to redirect to are:
Immediate: Busy / No answer:
Is Telstra VPN to be
included?
Yes No
If yes:
Telstra national Corporate
VPN International Call Plan
InfoCall Secured Access
Yes No
Type: InfoCall Standard InfoCall Extra
Telstra Corporation Limited
ABN 33 051 775 556
Page 5
Please provide any further
information regarding your
requirements that has not
already been outlined above.
Our Customer Terms means
the Standard Form of
Agreement formulated by
Telstra for the purposes of
Part 23 of the
Telecommunications Act 1997
(Cth), as amended by Telstra
from time to time.
You should read the full
terms of the service which
are set out in Our
Customer Terms at
http://www.telstra.com.au/
customerterms/ or obtain a
copy from Telstra.
Privacy
Telstra’s Privacy
Statement is available at
http://www.telstra.com.au/
privacy or by calling
Telstra on 1800 039 059.
By signing you warrant that
you have the authority to
make this application on
behalf of the Customer named
above.
I apply for the service(s) described in this Application Form and acknowledge that if my
application is accepted:
it will be provided on the terms and conditions (including fees and charges) set out in
this Application Form and Our Customer Terms (as amended from time to time);
the service is subject to a minimum term of 3 months;
if I cancel the service within the 3 month term I will incur a cancellation charge; and
an override code can be used to connect long distance and international voice calls to
other service providers but 64K data calls may fail.
Privacy
I agree, and will ensure that any of our related bodies corporate which receive services
connected with this Application Form and our representatives are aware, that Telstra may:
(a) collect, use and disclose information about each of us (including for marketing
purposes) in accordance with Telstra’s Privacy Statement; and
(b) give to, seek and obtain from, a credit reporting agency, information (including personal
and credit information) about each of us to assess your credit worthiness.
SIGNED by me, for and on behalf of the Customer as its authorised representative:
Signature
Date
Print Name
Position
click to sign
signature
click to edit
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