ipstar satellite broadband application form

IPSTAR SATELLITE BROADBAND APPLICATION FORM (SCHEDULE 1)
Sales Agent Name
Return form by one of the options below:
IPSTARWEB
EMAIL [email protected]
Office Use
FAX
03 9480 2831
POST Level 2, Building 2, 13A Albert St, Preston VIC 3072
CUSTOMER DETAILS
Billing Address
Select category of application. Tick ONE only:
Residential
Business
Street
Indigenous Community Council No.
Dr
Mr
Suburb/Town
Mrs
Ms
Miss
State
Postcode
First Name
If address not provided - please specify below:
Surname
Latitude
Phone (Incl. Area Code)
Postal address (if different to above)
Longitude
Fax (Incl. Area Code)
Mobile
/
Date of Birth DD/MM/YYYY
Have you received a Government satellite broadband subsidy at
this address in the last 3 years?
Yes
No
/
COMPANY DETAILS (FOR BUSINESS APPLICATIONS ONLY)
Complete this section only if this is a Business Application (as per your Customer Declaration Form)
Company Name
Number of Employees*
*Limit of 20 employees to be eligible for the Australian Government's
Australian Broadband Guarantee program.
GST exempt? (Y/N)
ABN
INSTALLATION DETAILS
1. Are you the owner of the building?
Yes
No
2. If no, has the owner given authorisation?
Yes
No
3. What is the height of the building?
1 Storey
2 Storey
4. Does the building contain asbestos?
More than 2 Storey
Yes
No
5. What is the roof made of?
Provide installation contact person and address details below.
Leave blank if the same as the billing address above.
Contact Name
Phone (Incl. Area Code)
Street
Suburb/Town
eg. Metal/Tin, Ceramic/Slate, Cement, Asbestos
State
Postcode
5. What are the walls made of? Internal:
External:
eg. Double Brick, Block, Timber, Plaster, Mud, Cement
PC Requirements - PC MUST have ethernet port and Windows
2000 or later. For more details phone IPSTAR.
EMAIL CORRESPONDENCE
It is mandatory that you have an email address for customer information and data usage notifications.
1. Send ALL notifications to my current email address below.
Current Email
2. OR, set-up a free IPSTAR email (insert preferred address)
@internetsat.com.au
Please note: Additional free IPSTAR email addresses can be set-up after
installation by phoning IPSTAR Customer Service.
IPSTAR Australia Pty Ltd ACN 107 338 901 ABN 85 107 338 901
SATELLITE BROADBAND APPLICATION FORM V1.1
Page 1 of 3
PLANS AND ACCESSORIES
EXCESS PLANS
PEAK SPEEDS
PEAK
(kbps)
DATA (GB)
OFF-PEAK
DATA (GB)
EXCESS DATA
CHARGE
STANDARD
PRICE/MONTH
6 MONTHS
HALF PRICE
IP-Saver 1.5GB Excess
Rapid 3GB Excess
Rapid 5GB Excess
512/256
Maximum
Maximum
0.5
1
2
1
2
3
Excess Data 5c/MB
Excess Data 5c/MB
Excess Data 5c/MB
$18.50
$23.95
$33.95
$9.25
$11.98
$16.98
Rapid 7GB Excess
Maximum
3
4
Excess Data 5c/MB
$43.95
$21.98
Rapid 10GB Excess
Maximum
4
6
Excess Data 5c/MB
$53.95
$26.98
Rapid 12GB Excess
Maximum
4
8
Excess Data 5c/MB
$63.95
$31.98
Rapid 15GB Excess
Maximum
5
10
Excess Data 5c/MB
$73.95
$36.98
Rapid 18GB Excess
Maximum
6
12
Excess Data 5c/MB
$83.95
$41.98
Rapid 28GB Excess
Maximum
8
20
Excess Data 5c/MB
$143.95
$71.98
Rapid 40GB Excess
Maximum
10
30
Excess Data 5c/MB
$243.95
$121.98
OFF-PEAK
DATA (GB)
SHAPING (AFTER
MONTHLY QUOTA)
STANDARD
PRICE/MONTH
6 MONTHS
HALF PRICE
SHAPED PLANS
PEAK SPEEDS
PEAK
(kbps)
DATA (GB)
IP-Saver 1.5GB Shaped
Rapid 3GB Shaped
Rapid 5GB Shaped
512/256
Maximum
Maximum
0.5
1
2
1
2
3
Slowed to 64 kpbs
Slowed to 64 kpbs
Slowed to 64 kpbs
$18.50
$27.95
$37.95
$9.25
$13.98
$18.98
Rapid 7GB Shaped
Maximum
3
4
Slowed to 64 kpbs
$47.95
$23.98
Rapid 10GB Shaped
Maximum
4
6
Slowed to 64 kpbs
$57.95
$28.98
Rapid12GB Shaped
Maximum
4
8
Slowed to 64 kpbs
$67.95
$33.98
Rapid 15GB Shaped
Maximum
5
10
Slowed to 64 kpbs
$77.95
$38.98
Rapid 18GB Shaped
Maximum
6
12
Slowed to 64 kpbs
$87.95
$43.98
Rapid 28GB Shaped
Maximum
8
20
Slowed to 64 kpbs
$147.95
$73.98
Rapid 40GB Shaped
Maximum
10
30
Slowed to 64 kpbs
$247.95
$123.98
Important Notes: Plans only available on new installations eligible for the Australian Broadband Guarantee.
^No lock-in satellite contract term is 30 days. All usage quotas include uploads and downloads.
Broadband peak data time is 12 noon to 11pm. Off-peak data time is 11pm to 12 noon. Sydney time.
FREE 36 month warranty included. Warranty cannot be transferred to another provider and ceases to apply if
you cancel your service. Additional charges for travel may apply in certain remote areas after the first 12 mths.
TICK
TICK
No lock-in
contracts^
OPTIONAL ACCESSORY - CREATE A WIRELESS NETWORK
WIRELESS N HOME ROUTER
LINKSYS E-1000
$110.00 (INCLUDES FREIGHT)
AUTHORISATION
By signing this application you agree your application for service is subject to the Terms & Conditions supplied with this contract.
You acknowledge that you have read and understood the information in this form and declare that the information you have given
on this application is true and accurate to the best of your knowledge. You also give IPSTAR consent to obtain and use credit
information about you, including information about your consumer credit history (eg. household and personal financing) and if
applicable, your commercial credit history (eg. as a sole trader). You also acknowledge that IPSTAR may share your personal
information with a Third Party Supplier in order to provision the Program Service.
SIGN HERE
DATE
/
/
If signing for and on behalf of the Applicant (insert full name & position above):
IPSTAR Australia Pty Ltd ACN 107 338 901 ABN 85 107 338 901
SATELLITE BROADBAND APPLICATION FORM V1.1
Page 2 of 3
PAYMENT DETAILS
OPTION 1 - Credit Card Authorisation
"You" request and authorise IPSTAR Australia Pty Ltd ID 368185 to arrange, with its own financial institution, a debit to your
nominated account through the Bulk Electronic Clearing System (BECS) any amount IPSTAR Australia Pty Ltd has deemed payable by
you. Please note that we cannot accept AMEX or Diners Cards.
VISA
MASTERCARD
Name on card
Signed By
Card Number
Expiry - Month
Year
Today's Date
IPSTAR Australia Pty Ltd
Direct Debit User ID 368185 ABN 85 107 338 901
OPTION 2 - Direct Debit Authorisation
"You" request and authorise IPSTAR Australia Pty Ltd ID 368185 to arrange, with its own financial institution,
a debit to your nominated account through the Bulk Electronic Clearing System (BECS) any amount IPSTAR
Australia Pty Ltd has deemed payable by you.
Full Name/Company
BSB (6 digits)
Financial Institution
Account Number
Branch
Account Name
By signing you are providing us with a valid instruction in respect to your Direct Debit Request, you have understood and agreed to
the Terms and Conditions governing the Direct Debit arrangements between you and IPSTAR Australia Pty Ltd and in your Direct
Debit Request Service Agreement.
Signed By
Today's Date
If signing for and on behalf of the Applicant (insert full name & position above):
DIRECT DEBIT SERVICE AGREEMENT
Our Commitment to you, Drawing arrangements: Upon receipt of your signed Application Form we will commence your IPSTAR Australia Pty Ltd
drawing arrangements on your account, details of which you have provided, 7 days after invoicing for the service, for the duration of the contract
and then on a month to month basis, unless terminated in accordance with the Agreement. Where the due date falls on a non business day for all
future drawings under the Client Services Agreement, we will draw the amount on the next business day. You agree that we may debit from the
account specified in the Direct Debit Authorisation each Repayment on the Relevant Repayment Date; and such other amounts at such other
times as authorised by you from time to time in accordance with the terms of the Agreement. We reserve the right to cancel the IPSTAR Australia
Pty Ltd drawing arrangements if three or more drawings are returned unpaid by your nominated Financial Institution and to arrange with you an
alternate payment method. We will keep all information pertaining to your nominated account at the Financial Institution, private and
confidential.
Your Rights: You may terminate the IPSTAR Australia Pty Ltd drawing arrangements at any time by giving written notice to us. Such notice should
be received by us at least 30 days prior to the due date. You may stop payment of a drawing under the IPSTAR Australia Pty Ltd drawing
arrangements by giving written notice to us. Such notice should be received by us at least 30 days prior to the due date. You may request a change
to the drawing amount by varying your original agreement, but the frequency of IPSTAR Australia Pty Ltd drawings will remain monthly as per the
terms and conditions. Where you consider that a drawing has been initiated incorrectly (outside the IPSTAR Australia Pty Ltd drawing
arrangements) you should take the matter up directly with us.
Your Commitment to us, Your Responsibilities: It is your responsibility to ensure that sufficient funds are available in the nominated account to
meet a drawing on its due date. It is your responsibility to ensure that the authorisation given to draw on the nominated account is identical to the
account signing instruction held by the Financial Institution where the account is based. It is your responsibility to advise us if the account
nominated by you to receive the IPSTAR Australia Pty Ltd drawings is transferred or closed. It is your responsibility to arrange with us a suitable
alternative payment method if the IPSTAR Australia Pty Ltd drawing arrangements are cancelled either by yourselves or the nominated Financial
Institution.
IPSTAR Australia Pty Ltd ACN 107 338 901 ABN 85 107 338 901
IPSTAR SATELLITE BROADBAND APPLICATION FORM V1.1
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