Full qualification and service application This form will give us all the information we require to perform a full check for eligibility. You will be contacted by us for your authorisation before we undertake to install a service. Regional ADSL2+ Bundle 250GB Name* First Last Contact Telephone*Email* Date of birth* DD MM YYYY Service Address* Street Address City/Suburb State Post Code Delivery Address* Same as previous Street Address City/Suburb State Post Code Service Telephone NumberIf you have a telephone number at this address enter it here. We need your "Full National Number" which is the area code, and the phone number all in one. eg. EveryNet's FNN is 0261004750 If you are applying for a bundle service you dont have to enter a number here, however if you have one it can make service installation much faster Regional ADSL2+ Bundle 250GB* Price: $ 89.95 This table lists the available options for your selected plan To save you headache hardware is pre-configured for your connection and is covered by a 12 month replacement warranty with us.Line Activation*My Telephone Line is staying with another carrierTransfer Existing LandlineExisting landline socket with dial toneExtensive line work requiredModem/Router*I will provide my own hardwareModem/Router: TPLink ADSL 2+ with WiFiContract Length*24 months ($165 early termination fee)12 months ($80 early termination fee)6 months ($55 early termination fee)1 Month (no early exit fee)This contract represents an agreement that you will use the service for the indicated period of time at the address you have it connected at. If you move, or the landline is terminated for any reason, or you terminate this service for any reason there will be a service termination fee as indicated. First Invoice Total $ 0.00 Choose a usernamePlease choose the username you would like to have. We can't give you a promise here, but if its not already in use and it's not offensive - its yours. If you don't choose a username, we'll choose one for you based on your real name. Users names must be inoffensive, and not already used by another EveryNet user. They must be at least 6 characters in length and cannot start with a number. CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.