Emerge LBNCo Application Form Step 1 of 2 50% Emerge Re-seller IDBusiness NameABNName of DirectorDate of Birth* Date Format: DD slash MM slash YYYY Site Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Site Contact Name* First Last Site Contact Mobile No.*Site Contact Landline No.*Site Contact Email Choose your LBN tier*Plans are priced as per month costs.LBN Pro $132/monthLBN Standard $88/monthLBN Basic $77/month4G Failover Option?*Price is per monthYes $25.00NoVoIP Number Port (Optional) SIP Line $10/month (inc national & mobile calls) Modem Selection*4G Modem Option (one off charge of $249 inc gst)Standard Modem (one off charge of 149 inc gst)BYO ModemNumber:Current Provider:Account No:Monthly Total Price: $ 0.00 One Time Total Price: $ 0.00 Credit Card MasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Account Name*BSB*Account Number*Financial Institution Name*Authorised Signatory (Print name)*Position/Title:*Date Date Format: MM slash DD slash YYYY SignatureNBN Broadband: Terms and Conditions* 1. All prices quoted are inclusive of GST. 2. Total minimum commitment is dependent on the plan you choose; full pricing can be viewed on the Product Sheets for the specific plan 3. Dishonored direct debit payments may incur a charge. 4. Acceptable Usage Policy applies. 5. If you choose to cancel your service or it is disconnected for any reason within the contract term you will be charged an early termination fee of $0. You must provide 30 days’ notice to us to disconnect a service. 6. We will deliver your service to the Network Boundary Point at your premises, which is defined as the physical port or ‘UNI’ on the NBN Network Termination or port on the Home Network Gateway if selected. The cabling that is required in your premises beyond the Network Boundary Point is your cost and responsibility, as is the provision of a suitable 240V AC power outlet. 7. You must obtain the consent of the property owner to have the NBN installation performed. 8. The installation will be performed during business hours, and you will need to be home to provide access for the installation technicians. If you select to take the Home Network Gateway and choose the Professional Installation option, a second appointment will be required. 9. A single static IP address is provided which may be changed due to technical and operational reasons by providing 30 days’ notice. 10. Many factors affect speeds including but not limited to: network configuration, line quality and length, customer premises interference, traffic, hardware and software. 11. Data Allowance: each month includes both upload and www.emergeinternet.com.au Tel 1300 294 090 E2, 118 Railway Street, West Perth 1/11/2019 download traffic for that billing period and quota not used in a month is not carried forward to the next month. 12. If you have chosen a shaped plan, once you have reached your usage allowance, the speed of your service will slow to 256kbps. 13. If you have chosen an unshaped plan, excess data used will be charged at $0 per GB in 1 Mb increments (1 Gigabyte = 1024 Megabytes). 14. The New Development Charge (NDC) which is a one-time charge of $300 will apply to all new orders for NBN in new development locations and applies to the first connection at a premise in a newly developed area (e.g. new housing estate/suburb or sub-division of existing property) with no pre-existing telecommunications infrastructure. 15. A Subsequent installation charge of $300 will apply to connections where NBN co are required to activate a copper pair to complete the installation. 16. For more information about Speed Tiers please read Emerge Internet "Speed Tiers" document in https://www.emergeinternet.com.au/critical-information-summaries/Authorisation* I have read and understood Emerge Internet’s (55193764017) Standard Form of Agreement and agree to the terms and conditions outlined in this agreement. I understand that all bills are delivered by email delivery and that Direct Debit from either a bank account or credit card is required.Authorised Signatory (Print name)*Position/Title*Email*Date*Signature You must download and read our Critical Information Summary before submitting this applicationNameThis field is for validation purposes and should be left unchanged.