Telstra Temporary Service Request For 2010

Submission of this form is a request to Telstra for temporary telecommunications services during the 47th Elmore Field Days - 5 to 7 October 2010.

All requests must be received by close of business 17 September 2010. Requests received after this date may not be fulfilled.

Please fill in ALL the boxes ...

Legal Entity Making Application:
Person or Company Name:

Trading Name:

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:

New Account
Is a New Telstra Account Number Required? Yes No
If a new account is required, please supply your ACN:

Billing Address:

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 2009
Cancellation Date:
eg: 9 Oct 2009

Sponsor Icons - Tractor & Machinery Association, Telstra Countrywide, Field Days Association.

RFM CT Planter (RFM Ag Pty Ltd)
The Tractor & Machinery Association of Australia
Elmore Machine of the Year 2009

Proudly supported by Tractor & Machinery Association of Australia