Referral Mobile No. / Dealer Code:

My Details

A. Applicant details (this section is for business account only)

Company name ABN/ACN number

B. Applicant details (authorised person) — fields marked with ' * ' are mandatory

Title* Mr. Mrs. Miss First name* Last name* Address* Suburb* State* Post code* Email* Phone/Mobile* Fax

ID Checks

Identification (Photo ID required*)

Visa status* Australia Citizen/Resident Work Student Visitor

Driver's license / Passport number* Date of birth* (YYYY-MM-DD)

(Note: You have to provide a valid copy of your photo ID upon request.)

If you are not an Australian citizen/resident

Nationality Visa number Visa expiry date

Phone & Plan Details

SUBSCRIPTION DETAILS -Mobile phone service details

Mobile Number*

To select your new number / buy a premium number

(Please leave it blank if you have any difficulty with selecting your number from the list. E.Tel staff will contact you asap.)

To port your own current number from

(Your current service provider company name, e.g. Telstra, Vodafone, Optus etc.)

Post-paid account — Your account number with above service provider:

Pre-paid account — Registered date of birth (YYYY-MM-DD)

Mobile rate plan* Additional servicesIDD

New SIM Number

(Please enter your new SIM number, if you have a new E.Tel SIM card in hand.)

Voucher number

(Please enter your voucher serial number to activate your new SIM, if you already have a pre-paid voucher in hand.)

Your password* (4-digits) - For security reasons you may be required to quote your password when enquiring about your account status.

Payment

Payment options

Direct debit from credit card

Credit card details

Card holder Card type: Visa Card MasterCard Amex Card number Expiry Date /

*CVV/CVC last 3 digits check

Direct debit from bank account

Bank details

Account Name

(Your name on this account. eg. Robert Smith)

Name of Bank BSB number Account Number

Use pre-paid voucher (as above)

Auto-Recharge options:*

Auto-pay via credit card as above

Auto-pay via bank account as above

Use pre-paid voucher (purchase from E.tel or E.tel dealer)

(Note: If payment is rejected from your nominated account, a standard $30 handling fee applies.)

The space below is for additional comments. You may also use this box to specify a plan which cannot be selected in the above form:

By signing this form I agree my application for the Service(s) are subject to the full terms and conditions on www.etel.com.au, which I have read and understood, and is legally bound by the contract effective from the date I submit this form. I declare that the information I have given on this form is true and correct. I also give E.Tel my consent to obtain and use credit information about me/my company, including information regarding my consumer/company credit history. I agree that I am (or in the case that I'm signing on behalf of a company, the company is) bound by the terms and conditions and responsible for (as principal) all amounts that become due in relation to this account including delayed transaction items and also, if applicable, any early termination payment.