First Name

Middle Name

Last Name

Contact email

Current Site Address

Emergency Contact Name

Emergency Contact Email

Emergency Contact Mobile

DOB: DD/MM/YYYY

100 Point ID Copy Provided (Yes/No) 100 Point ID Copy Provided (Yes/No) Yes No

Plan PlanPlan: 1 x TQMS Mobile Plan – $25 per month (Ex GST)

Quantity

Total Monthly Cost (Ex GST)

Total Once Off Upfront Charge

Upfront Payment Status (Paid) Upfront Payment Status (Paid) Paid

Final Total Monthly Cost (Ex GST)

I have read agree to Critical information summary : https://telequip.net/wp-content/uploads/2023/06/CIS-Telequip-Mobile-SIM-Data-Only-Service-Including-Data-Bank.pdf Telequip Support number: 0740477000 I accept to pay the monthly charges to keep the service activated via my credit card or online portal supplied by Telequip. As an authorised representative of the company named above, I authorise TELEQUIP to undertake the work outlined above. I understand that this work may incur charges as outlined above. I have read agree to Critical information summary : https://telequip.net/wp-content/uploads/2023/06/CIS-Telequip-Mobile-SIM-Data-Only-Service-Including-Data-Bank.pdf Telequip Support number: 0740477000 I accept to pay the monthly charges to keep the service activated via my credit card or online portal supplied by Telequip. As an authorised representative of the company named above, I authorise TELEQUIP to undertake the work outlined above. I understand that this work may incur charges as outlined above. I Agree

Authorizing Name

Signature (Type Full Name as Signature)

Date (DD/MM/YYYY)

Office Use Only (Optional) Office Use Only (Optional) 100 Point ID Checked

Office Use Only: Allocated SIM Card Number (Optional)

Office Use Only: Issued Date (Optional)

Office Use Only: Issued (Optional) Office Use Only: Issued (Optional) Yes No