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info@voipex.com.au
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Residential VoIP sign up form
Select a VoIP phone plan
*
Please select an option
Casual VoIP phone - $4.95 per month
Basic VoIP phone - $9.95 per month
Plus VoIP phone - $29.95 per month
Add VoIP hardware?
No thanks
VoIP Adaptor - $79.95 delivered
New VoIP phone number, or keep your existing phone number?
New VoIP phone number
I want to keep my existing phone number
Existing phone number to port to VoIP
Current phone provider
Current phone provider account number?
Installation address
*
Installation suburb
*
Installation state
*
Please select an option
ACT
NSW
NT
QLD
SA
TAS
WA
VIC
Installation post code
*
Your details
Your full name
*
Your date of birth
*
Email address
*
Phone number
*
Identification type
*
Please select an option
Drivers license
Medicare card
State where ID was issued
None
ACT
NSW
NT
QLD
SA
TAS
WA
VIC
Identification number
*
Postal address
Postal suburb
Postal State
ACT
NSW
NT
QLD
SA
TAS
WA
VIC
Postal post code
Is your postal address the same as the install address?
Yes
No
Who referred you to VoIPex?
Payment details
Payment details
Credit card
Direct debit
Credit card type
MasterCard
Visa
Credit card number
0 / 16
Credit card expiry
Credit card CVV
Credit card authorisation
Yes
No
You request and authorise Voipex Pty Limited to arrange for any amount Voipex Pty Limited may debit or charge you to be debited through a secure credit card processing facilty from the credit card identified above.
Financial institution
Account holder's name
BSB number
Account Number
Direct debit authorisation
Yes
No
By accepting this Direct Debit Request you acknowledge having read and understood the terms and conditions governing the debit arrangements between you and Voipex Pty Limited as set out in this Request and in your Direct Debit Request Service Agreement.
Terms and conditions
I have read the Terms and Conditions and agree to be bound by them.
*
Yes
No
I have read the Acceptable use policy and agree to be bound by it
*
Yes
No
Applicants name
Application date
*
Sign Up
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