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eTalk Residential Services Application Form

Important: For your security, we will not request credit card numbers over the net. We will phone you on the daytime contact number supplied for your credit card details.

Payment Options other than Credit Card still require your credit card details as a guarantee of payment.

Customer Details:
Ltd Company	... Partnership ...Sole Trader
Business Name:
Trading as:
Street Address:
Suburb:
City/Town:
Postal Address:
Email Address:
Daytime Phone no:
Fax no:
Director's Full Name:
Director's Address:
Director's Full Name:
Director's Address:
*Trade References*
Contact Name:
Contact Phone No:
Contact Name:
Contact Phone No:
Contact Name:
Contact Phone No:
How do you wish to pay?
Payment Method :	*See note at top of page*
Phone numbers to be connected
Note: "Coded" access requires you to dial a 4 digit access code before you make a call, allowing you to choose between service providers."Non-Coded" access eliminates the need for any code - all of your toll calls will go through eTalk's network.
Phone numbers	....National Access xxxxxxxxxxInternational Access
	coded non-coded .... coded non-coded
	coded non-coded .... coded non-coded
	coded non-coded .... coded non-coded
	coded non-coded .... coded non-coded
	coded non-coded .... coded non-coded
	coded non-coded .... coded non-coded
*Site Details*
Exact name on your existing Telephone Account:
Current Provider:
Site Name:
Site Street Address:
Technical Contact:
PABX Make:
PABX Model:

Name of person who told you about eTalk:
*Submit your application(Please read the following first)*
Authority I/We apply for the service indicated above on the terms and conditions in this application for Toll call services and Net Tel's General Terms & Conditions and Rate Schedule/Proposal. I/We acknowledge receipt of a copy of your General Terms & Conditions. I/We authorise you to collect, use and exchange information about me/us for the purpose related to my/our use of the service. I/We acknowledge that you will hold this information at your offices and that you have rights of and correction of, information you hold about us/me. I/We authorise Net Tel to be my/our supplier for the services shown on this form. If I/We have selected "Non Coded" access, I wish to be able to use your service without dialing any prefix numbers and that means calls are automatically routed through the Net Tel network. I/We request that Telecom NZ/Clear Communications supplies you with full details of all telephone numbers associated with my account and I/We request that Telecom NZ/Clear Communications supplies be provided with Non Coded access. If I/We have selected "Non Coded" access, I/We hereby certify that I/We am/are a Telecom NZ/Clear account holder for the above number(s) to be registered and connected on the Net Tel network.
................................................ eTalk freephone 0800 555 222 email etalk@hotline.co.nz