Appointment of Advocate or Authorised Representative

Dear Customer,

If you wish to appoint an Advocate or Authorised Representative to deal with us on your behalf, please carefully read the instructions below:

• Complete the form on the next page;
• With proof of your identity, take it to a witness as indicated next;
• Sign the form in presence of a lawyer or doctor or pharmacist or Centrelink office or member of police as witness ; and
• Post it to us at the address above

1. What is an Advocate?

An “Advocate’ you appoint can deal with us on your behalf (including making a complaint) but:

(a) Cannot change your account or services; and (b) Cannot act on your behalf or access your information unless you are present and agree

2. What is an Authorised Representative?

An “Authorised Representative” you appoint can deal with us on your behalf as your agent (including making a complaint) and

(a) If you give them limited rights: has only those rights including any limitations you specify on access to your information ; and (b) If you do not give them limited right: has power to act and access information as if they are you

3. If we are not clear whether you intend to appoint an Advocate or an Authorised Representative, we will assume you only intend to appoint an Advocate.

4. We may also accept a person who holds an appropriate power of attorney or Guardianship order as Advocate or Authorised Representative for a customer. Please forward a certificated copy of the Power of Attorney or Guardianship order together with this form (signed by the Attorney or Guardian for the customer). We may need to have the documents checked before we can accept the appointment.

5. To protect your privacy and security and to minimize the risk of fraud, our requirement is that this Appointment be submitted by post as a signed original, witnessed by a lawyer or doctor or pharmacist or Centre link officer or member of the police.

Date: _______

To: E.Tel Telecommunications Pty Ltd____

Account Type/s (circle): Landline Mobile

My Account ID:

Account holder name: (Note: This must be the actual account holder)

I wish to appoint either (circle one): an Advocate OR an Authorised Representative

The person I appoint is: ___________________________ Their Email Address is: ___________________________ Their landline number is: ____________________ Their mobile number is:___________________ Their Address is: ____________________________________________________

Limitation/s on authority of Authorised Representative:

My appointment and authority:

I authorise you to deal with the above person as my Advocate or Authorised Representative (as applicable). I acknowledge responsibility for anything my Advocate or Authorised Representative does on my behalf within their authority as described in this Appointment. I release you from any claim I might otherwise have against you, based on anything you do in reliance on this Appointment. You may assume that you are dealing with the relevant person if they identify themselves as such when you contact any of the contact numbers / addresses above. The appointment continues until I revoke it in writing.

My signature: ______________________________________________

Name of Witness: ________________________________________________

Signature of Witness: _________________________________________________

Qualification and address of Witness: ________________________________________________ (Lawyer/ Doctor/pharmacist/Centrelink officer/police)

Confirmation by witness: I confirm that the person signing above has produced evidence of their identity