CUSTOMER APPLICATION & PAYMENT AUTHORITY FORM
www.nitro.net.au
Phone: 1300 793715 or 0429 654 055
Please print this form, fill in and fax to:  1300 793716
or post to: 25 Leichhardt St, Mundubbera QLD 4626
1. Plan Selection  
  •  
    • NOTE: Please refer to the www.nitro.net.au web site for complete pricing and terms & conditions of service.
       
     ADSL:               (Plan Name)  Amount: $
     Dial-Up:            (Plan Name)  Amount: $
     Special Offer  Amount: $

     

     

    Note: $150 disconnection fee applies if ADSL service is terminated within under 6 months.
    2. Customer Details
    Full Name:   Date of Birth:
    Company Name:   ABN:
    Billing Address: 
    Town/Suburb:   State.:  Postcode:
    Home Ph:   Work Ph:   Mobile: 
    Email Address: (for Notices & Billing)  
    How did you hear about Nitro? Web Site Friend Flyer Google Yahoo Brochure
    3. Payment Method
    CREDIT CARD: VISA MasterCard Bankcard
    Card Number:       :
     Expiry Date:
      .
  •  
    • I authorise Nitro.net.au or its nominee to debit this credit card for my setup and ongoing service charges.
    Cardholder Signature:   
    Print Name:
    Other payment methods by arrangement.
    4. Authority to Pre-select
       
    ADSL Service Details:      Provision New Service      Churn to Nitro Service      Maintain Existing Nitro Service
    ADSL Service Number:(incl area code) 

     
          Current Provider: 
    :
    ADSL Site Address:
     State:  
    Postcode:
    Preferred Username:                                                                            

       
     Preferred Password:

         (Password must contain at least 6 characters)

  •  
    • I agree to abide by the Terms & Conditions of service and Service Rates published online on the nitro.net.au web site.
  •  
    • I am not under any contract with another provider and I will inform Nitro.net.au in writing of any changes to my details.
  •  
    • I confirm that I am over 18 years of age and I am authorised to enter into this agreement with Nitro.net.au.
    Customer Signature:   Date: 
    Print Name:   Title/Position: 

    Copyright © 2007 Nitro.net.au.
    OFFICE USE  Date Processed:     Initials:     Dealer Code: