Telstra Temporary Service Request For 2011

Please fill in ALL the boxes ...

Application Authorised By:
Name:

Telephone Number:

Fax Number:

Email Address:

Account Details

Existing Account
Consolidate to an existing Telstra Account? Yes No
If `Yes' Account Number:

OR
Consolidate to an existing Telstra Phone Number? Yes No
If `Yes' Telephone Number:

Previous Field Days' Services
Have you exhibited at previous Elmore Field Days? Yes No
If `Yes' please list the services you have accessed previously:

Site Information And Service/Equipment Requested
Site/ Number:

On Site Contact Person:

Mobile Phone Number:

Type of Service Required:
Standard Telephone: / Other (detail below)
Quantity of lines required:
Long Distance Carrier Choice:

Access Level: Open / Local, STD & Mobile / Local Only
Equipment Required: Socket Only / Rental Telephone Required
Additional Requirements:

Service Dates
Connection Date:
eg: 7 Oct 2011
Cancellation Date:
eg: 9 Oct 2011