PARTNER DETAILS END CUSTOMER NAME END CUSTOMER CONTACT DETAILS

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					                                              PARTNER DETAILS
Company Name:                                                Commercial Contact-Name/Title:

Billing Address:                                                   Commercial Contact - email:

City:                                                             Commercial Contact - Phone:

State / Pcode:                                                  Technical Contact - Name/Title:

ABN:                                                                 Technical Contact - email:

Wirefree Sales:                                              Technical Contact Contact-Phone:

Wirefree Engineer:
        END CUSTOMER NAME                                      END CUSTOMER CONTACT DETAILS
Company Name:                                                            Contact Name:
Trading Name:                                                                   Position:

Address:                                                                     Telephone:

City:                                                                             Email:

State / Pcode:                                                           Rooftop Access


                                                      SERVICE
Service Type            SLA              Speed         Contract             Installation    Monthly Fee
                                                       Term


Data Included:                           Excesas Data / MB
Notes




_________________________________________________________________________________                 1
                   Wirefreebroadband Pty Ltd 11/397, Smith Street, Fitzroy, VIC. 3065
                    Phone : 1300 655 482 Email : sales@wirefreebroadband.com.au
                                 Web : www.wirefreebroadband.com.au
                                                  AUTHORISATION

      I hereby apply for the WireFree Broadband Services and acknowledge that the Service will be provided subject to
      the provisions of WireFree Broadband Basic Carriage Service Tariffs including WireFree Broadband General Terms
      and Conditions applicable to the Telecommunications Service (both as amended from time to time) made pursuant
      to Part 9 Division 5 of the Telecommunications Act 1991.
I acknowledge that the WireFree Broadband Service is provided on the basis of the customer network dimensions
included in this order. At any time, should the actual network requirements vary, WireFree Broadband will consult to
determine my new requirements.
I further acknowledge that, if the IP addresses provided by me are not registered, at a subsequent time I may be
required by WireFree Broadband to modify any or all of these addresses.
I confirm that I have read the full Terms and Conditions or have viewed the full Terms and Conditions on the WireFree
Broadband website


      Signature:                                                     Date:


      Name                                                          Position:
      (Print):

                         TECHNICAL INFORMATION (OFFICE USE ONLY)
 Service Provider Interface:                                     Frequency

 Point of Interconnect:                                          Location

 Vlan ID:              Existing                                  Subnet Mask

                          New                                    Gateway

 VPI/VCI:                                                        Primary DNS

 SU IP:                                                          Secondary DNS

 Customer MON
 Point (IP Address)                                              SU Mac Address
 BSU

 SU

 Notes:




_________________________________________________________________________________                      2
                   Wirefreebroadband Pty Ltd 11/397, Smith Street, Fitzroy, VIC. 3065
                    Phone : 1300 655 482 Email : sales@wirefreebroadband.com.au
                                  Web : www.wirefreebroadband.com.au
_________________________________________________________________________________   3
             Wirefreebroadband Pty Ltd 11/397, Smith Street, Fitzroy, VIC. 3065
              Phone : 1300 655 482 Email : sales@wirefreebroadband.com.au
                           Web : www.wirefreebroadband.com.au

				
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