AUTOGRID CANCELLATION FORM

							                                   AUTOGRID CANCELLATION FORM

                Please print this form, complete the relevant Section, and fax it to the Autogrid Helpdesk on 1300 78 11 01.
                  Also please attach a formal request on your company letter head and signed by a Authorized Personnel

Please note that the Autogrid Service desk needs to be notified 15 working days prior to the date of Cancellation. These timeframes are
effective when your request is received between 8:30am and 5pm Monday to Friday.

Updates on the progress of your changes can be obtained by calling the Autogrid Helpdesk on 1300 78 11 00.

Date Completed by Autogrid (internal use only):___________________



                         ALL FIELDS OF THIS SECTION MUST BE COMPLETED
  Your Contact
  Details
                         Trading/Business Name                                       ________________________________
                         Dealer Code                                                 ________________________________
                         Site Address                                                ________________________________
                         Contact Name (must be authorized contact):                  ________________________________
                         Title (Network Administrator or Business Owner):            ________________________________
                         Signature                                                   ________________________________
                         Email address:                                              ________________________________
                         Ph Number:                                                  ________________________________
                         Fax Number:                                                 ________________________________



                     SELECT THE TYPE OF CONNECTION BY TICKING THE BOX NEXT TO THE RELEVANT HEADING
 Type of
                      Autogrid Direct Account
 Connection

                      Autogrid Connect Account




 List Of Emails
                          Email

                              1.     _______________________                         6. ________________________

                              2.     _______________________                         7. ________________________

                              3.     _______________________                         8. ________________________

                              4.     _______________________                         9. ________________________

                              5.     _______________________                         10. _______________________




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    Other
    Services
                         VPN Username (Autogrid Connect Username)           Internet Proxy Username

                             1.   _______________________                   1. _______________________

                             2.   _______________________                   2. _______________________

                             3.   _______________________                   3. _______________________

                             4.   _______________________                   4. _______________________

                             5.   _______________________                   5. _______________________




    To request a cancellation, please complete the form and fax the form along with a formal request on a
                                           Company Letter Head .
                                     Autogrid Helpdesk on 1300 78 11 01.


                                     For any other changes not specified in this form,
                                    Please call the Autogrid Helpdesk on 1300 78 11 00.

,




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