Applicant name

Are you an exsisting Titan Internet customer

First name

*

Surname

*

Telecom account holder:

First name

*

Surname

*

Is your Telecom account Residential or Commercial?

Residential Commercial

Telecom Account number

* (9 digits)

(Where Telecom charges apply, this is the account the product or Service will be charged to.
It is printed on the top right hand corner of the first page of every Telecom account)

Your Titan Internet username ( Note if you are a new customer please indicate your preferred username )

*

Email address

*

Contact Details

Business number

*

Business Fax number

After Hours Contact Number

*

Current Postal Address ( Street )

*

PO Box

Suburb

*

Town / City

*

Service Request details

Phone number the FastADSL service is to be connected on

*

I want to be installed on a new line.

Yes No

Select Jetstream pricing option (choose one)

Standard price including installation 
charge of $300 inc GST, no fixed
 term of agreement


Best time to call

What date would you like Telecom to contact you?


Computer system Information

Are you using a PC or Mac?

Pc Mac

What operating system are you running?

Do you have more than 30 Megs Hard drive spare?

Yes No Don't Know

How much ram do you have?

Don't Know

What type of processor are you running:

Don't Know

Computer Manufacturer (Make): 

Don't Know

What computer model is it?

Don't Know

Configuration options

(For an external ADSL modem)

Is your computer connected to a network?

Yes No Don't Know

Do you have an installed Ethernet Card?

Yes No Don't Know

If no do you want Telecom to supply the Ethernet Lan card?

Yes No Don't Know

Do you have a spare PCI Slot?

Yes No Don't Know

Third-party modems

If you have or are going to buy your own ADSL modem, what make/model is it?

Make/Vendor:

Model:

Additional information or comments:

    

 

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