Powercom Pacific : Business Sign-up Form

Service

Company Name

Company Contact Last name:

Company Contact First name:

B/H Contact Telephone# :

A/H Contact Telephone# :

City/Suburb:

Business Address/Street :

Postcode :

Email :

Drivers license# :

Date of birth :

Last monthly bill:

Telephone numbers to connect (fill in the phone number including the area code without the zero before the area code):

Telephone number #1 :

Telephone number #3 :

Telephone number #2 :

Countries most frequently called

Country #2

Country #1

Current long distance carrier :
(eg Telstra, Optus etc)

Current local call carrier :
(eg Telstra, Optus etc)

Do you also want to become a preselected customer ?

Yes, I want to become a pre-selected customer for national & international phone calls & calls to mobile.Yes, I want to become a full service customer for all local, national, international & calls to mobile, including the line rental charges on one bill.Please also provide me with an internet connection - I would like one of your consultants to contact me and tell me about this months specials.

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