PlaNet Broadband Order Form

• Please fill out the relevant fields and click on Submit.
• Any fields marked with an * must be completed.

Telecom Connection fee:
If a Telecom contractor needs to visit your premises and install a line for Jetstream, or install a filter for a monitored house alarm, the cost is $149

	Plan Name :		FS/128 1gig FS/128 3gig FS/128 6gig FS/128 15gig FLATOUT 10 FLATOUT 20 FLATOUT 40 *
	Connection type : Choose from, Connection Only, Connection and wiring, Have monitored house alarm		Connection Only Connection and wiring Have monitored house alarm *
	Is your phone account with Telecom Res or Bus :		Residential Business *
	Retain dialup backup at rate of $5/month
	Applicant Name :
	Name :		*
	Phone line Account Holders Name :		*
	Phone Account Number only needed if you are a Telecom client :		*The 9 digit number on your Telecom phone account,
	Phone line Company Name :		Telecom TetstraClear Other *
	Telephone number of the line Broadband is to be installed on :		*		(area code and, number)
	Connection Address     Street :		*
	Suburb :		*
	Town/City :		*
	Your E-mail Address :		*
	Contact number (business hours):				Area code and number
	Contact number ( Home ):				Area codeand number
	Mobile number :				Mobile number
	Quote For Router Supply And Install Needed?		YES  NO
	If Router quote request is yes, please fill in box below.
	Computer type and Operating System?
	Questions and comments
	In the event of non-payment of invoice by the Client, all costs and disbursements incurred in the recovery of the invoiced amount will be payable by the Client