GT - RemoteISP

Do you live within 8Klms west of our Mt Grey Tower?? *

Yes- Proceed
No? Please fill out our RURAL application. https://remoteisp.com.au/goulburn-internet/
Not Sure. Give us a Call 0422736683, Option 2, Please do not proceed.

Name *

First

Last

Date of Birth *

Just to match your identification that needs to be viewed on the day of installation.

Street Address *

Suburb *

State *

Postcode *

Home Phone Number *

Write None for no home phone

Mobile Number *

Does your mobile phone work at home? *

Are you interested in our Unlimited home phone? *

Email Address *

Email

Confirm Email

Residential plan details *

Installation Costs *

If for any reason we cant install you, you will not be charged.

Would you like a Backup Battery installed? *

*Modem and mobile devices. 700VA 20 Mins approx. 1000VA 30 Mins approx. 1500VA 50 Mins approx. 2200VA 70 Mins approx.

Would you like a static IP? *

Upgraded Wi-Fi, Internal and external *

Did a friend refer you ?

Please advise their full name and phone number.

Additional Notes

Do you require a RemoteISP email address? *

Wi-Fi (ssid) Name *

Property Name, Last name etc etc.

Password for your Wi-Fi *

8 characters min. 12 characters max.

Contract 1, I will read and understand the terms and conditions on www.remoteisp.com.au web site set out in the current version at https://remoteisp.com.au/tc/ *

Contract 2, I agree to the above nominated contract term and installation payment method and understand its paid in advanced on the day of the install *

Contract 3, I understand i will require to provide ID and Signatures on the day of the installation *

We use and App to capture ID's, Signatures and Photos of the Installation for Quality purposes.

Signature