Ethernet Services Order Form | Fantel

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Ethernet Service Application

Section A. Existing Account
Existing Account Number:
If you're already a Fantel customer. Please enter your Fantel account number here.
Section B. Address
Enter the address where the service will be connected. The service will be installed at the Main Distribution Frame (MDF) of the premise.
*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Enter the address of where you want the National Broadband Network active.
Section C. Billing Address
If the billing address is the same above just put a tick in the checkbox, otherwise, please enter all fields below correctly.
Billing Address
- same as above
Service Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Enter the address of where you want the National Broadband Network active.
Section D. Contact Details
Details entered here will become the authorised account holder.
Your Name*
First Last

Account holder name.
Date of Birth*

Required for security purposes
Driver's Licence
Phone*
This is used so that we can contact you.
Mobile
Email*
Company Name
ABN / ACN
Section E. Payment Details
By filling out this section, you hereby request Fantel Pty Ltd (Fantel), until further notice, to arrange payment of your internet account, by debiting the credit card. You acknowledge that this request may be terminated at any time by Fantel or by notice in writing from you.
Card Type*
- VISA
- Mastercard
- AMEX
Name on card*
VISA Card Number*
Mastercard Number*
AMEX Card Number*
Expiry Date*
e.g if the expiry date is 05/17 just enter 0517 in this field.
CVV or CVC*
This is the 3 digit code at the back of your card
CVV or CVC*
This is the 4 digit code just above the AMEX card number.
Section H. Modem Router
or similar
Router Purchase
- Billion BIPAC7800NXL or similar
Section I. Service Details

Enter the telephone number where the Ethernet Service is to be activated on.
Service Number*
Enter your existing telephone number here and please include the area code.
Section J. Term
Choose The Contract Term*
- 12 months
- 24 months
- 36 months
Section K. The Plan
Choose Your Plan*
Your minimum monthly cost: $899.00

Critical Information Summary
Your minimum monthly cost: $485.00

Critical Information Summary
Your minimum monthly cost: $440.00

Critical Information Summary
Total Cost Upfront
$ 0.00
Section L. Agreement and Authorisation

By submitting this form you agree to the following:
*
- I have read, understood and agree to abide by Fantel's Terms and Conditions. I have also read and accept the Critical Information Summary.
*
- I authorise Fantel to direct debit my credit card the amount on the invoice at the time the invoice was generated.
Section N. Comments
Your Message

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