1Customer Information
Legal Entity: / ACN: / ABN:
Trading As: / Years Trading:
Contact Name: / Position:
Date of Birth: / (if Sole Trader) / Drivers License Number: / (if Sole Trader)
Telephone: / Facsimile: / Email:
Site Address: / State: / PC:
Billing Address: / State: / PC:
2 Porting Authority
I request to Port the specified Mobile Service Number(s) listed in this section to iTel Communications
I declare that I have a contractual right to the Mobile Service Number(s) and am as such authorised to request porting of the Mobile Service Number(s).
I acknowledge that I have been advised that by Porting the Mobile Service Number(s), the service and/or Related Services associated with that Number may or may not be disconnected from the Losing Service Provider and may result in finalisation of the account for that service.
I authorise the Mobile Service Number, the Gaining Service Provider and the Network Type (iTel Communications) to be disclosed to other Network Providers and Portability Service Suppliers for the purpose of routing of calls, customer network fault management and routing of SMS messages to that MSN after porting activity.
I acknowledge that I have been advised by iTel Communications that if I continue to use the existing handset, it may need to be unlocked and/or reprogrammed prior to porting
Signed: / Date: //
3 Acknowledgment of obligations (to be completed by customer or authorised agent)
I acknowledge that I have been advised by iTel Communications that:
  1. although I may have the right to Port the Mobile Service Number, there may be costs and obligations associated with the existing mobile service and Porting the Mobile Service Number;
  1. I may or may not be in an existing contract with the current Service Provider; and
  2. The contract may or may not include an obligation to make early termination payments to the current Service Provider.
  3. I am completely responsible to iTel Communications for all charges incurred by me on the service number/s I have provided or are being provided for my use with this service

Signed: / Date: //
4. Agent Information
Agent Name: / Agent contact:
Agent Notes:
Company Name: / ACN/ABN:
5 Order Details
Plan:
(Telstra GSM) / Flex-iTel 28 / Flex-iTel 48 / Flex-iTel 78
Flex-iTel 98 / Flex-iTel 128 / Flex-iTel 158
Agreement timeframe
Handset: / Handset Type and Model:
Activation Type / Port / Standard New Number only / View my Bill Password
Mobile Number / Sim Card Number
(Office Use Only) / User Name
(optional) / Network
Required / Pass Code / State / Current Mobile Service Provider / Current Mobile Account Number
1
2
3
4
5
6
7
8
9
10
11
12
13
IDD, International Roaming and GPRS are automatically turned on at connection. Please indicate if you wish this feature turned off.
Authorised Representatives Name / Position
Authorised Representatives Signature / Date / //
Agent Name:
Notes: