residential-application - ICT Communications

Services Application Form

Agreement with ICT Communications [ABN: 88684890088]

Section 1: Customer Details

Title

First Name

Surname

Driver License

Date of Birth

Section 2: Service Address (PO Box not permitted)

Unit/Suite

Address

Suburb

State

Post Code

Contact Name

Phone

Section 3: Billing Address (If different from above)

Street / PO Box Address

Suburb

State

Postcode

Section 4: Plan Selection

Select the Service

Section 5: Direct Debit Details (Recommended)

Debit Options

5.1 Direct Debit to Bank Account

Name of Account Holder

Financial Institution

Branch

BSB

Account No

5.2 Direct Debit to Credit Card (For Amex 3.7% surcharge apply)

Card Type

Credit Card Number

Expiry Date

Card Holder's Name

Section 6: Agreements

I have read and understand the direct debit terms and conditions and authorise Telecommunication Payment Services to debit the account described.

I have read, understood and accept the terms & conditions and the terms of Star Telecom’s SFOA.