we can connect
  • Telephone
  • Internet
  • Electricity
  • Pay TV
  • Gas
  • Alarms
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Getting to Know you

Customer Details
Surname:
First Name:
Address you are moving FROM:
Address 2:
City/Suburb:
State:
Postcode:
Your NEW Billing Address (if different from above)
Address 1:
Address 2:
City/Suburb:
State:
Mobile:
Postcode:
Email:
Date of Birth:
 
Additional Comments:
Drivers License / Passport No:
Moving Information
Move out Date:
 
Move in Date
  
Let's Get Connected
Which services would you like us to connect?
Telephone
Internet
Pay TV
Electricity
Gas (LP)
Alarm Monitoring

Please enter the string shown in the image in the form.

  

Declaration I (the Customer) apply to 1300YesConnect for the connection of Services as listed above and for the supply of any equipment related to the provision of any of these services as specified in this Application and to the provision of information contained in this application to utility providers for this purpose. I acknowledge that: services are provisioned subject to the Customer Agreement and or Summary Customer Agreement which is a standard form of agreement for the suppliers of services from time to time. By signing this Application I agree that I have requested the connection of services as listed above: This Application is deemed accepted by 1300YesConnect at the time my Services are activated. We will collect personal information about you or information about your company, including but not limited to your electronic contact details such as email address and telephone service numbers. If you would prefer that we do not use your personal information and/or business information for direct marketing and/or for sending commercial electronic messages, as denied under the SPAM ACT 2003, please check this box
I acknowledge that have read and understand the terms and conditions of 1300YesConnect and agree to be bound by these terms and conditions

By Signing this form I declare that I am authorised to make this application and provide the consents, acknowledgements, authorisations and undertakings set out in this application form on behalf of all the clients listed in this application
Signature
 
Date
 
On completion of this form fax it to us on 1300 78 55 60