Change of Ownership Form

Complete the relevant customer section and the services to be transferred. The payment details section is shown only for an Incoming Customer. For enquiries, call GS Telecom on 1300 667 303.

Account Reference

Account Number *

Incoming Customer

Outgoing Customer

Outgoing Customer Details

Customer Name / Trading Name *

ABN / ACN

Final Billing Name

Email Address

Final Billing Address *

Suburb

State

Postcode

Billing Method

Authorised Representative Name *

Date of Birth

Position in Business

Contact Telephone *

Contact Fax

I request GS Telecom Pty Ltd to transfer the services listed in this application to the incoming customer. I understand that I remain legally liable for all charges associated with the service until the transfer takes effect.

Incoming Customer Details

Customer Name / Trading Name *

ABN / ACN

Billing Name

Existing GS Telecom Account Number

Billing Address *

Suburb

State

Postcode

Email Address *

Paper Invoice

Contact Fax

Authorised Representative Name *

Date of Birth

Position in Business

Contact Telephone *

I understand that I am applying to become the lessee of the GS Telecom services listed in this application and that I will be legally liable for all charges associated with the service from the date the transfer takes effect.

Services to Be Transferred

Transfer Date *

Service Numbers *

Site / Service Address *

Suburb

State

Postcode

ADSL / Alternate Service Address (if different)

Additional Services / Notes

Payment Details — Incoming Customer Only

Credit Card

Direct Debit

Name on Card *

Card Number *

Expiry Date *

Card Type

Name of Bank *

Account Holder *

BSB Number *

Account Number *

By signing, I request GS Telecom Pty Ltd, until further notice, to arrange payment of my account by debiting the credit card or bank account described above. A direct debit dishonoured charge of $10 may apply.

Authorisation Signature

Customer / Authorised Representative Signature *

Date *

I confirm that the information supplied is correct and that I am authorised to request this change of ownership.

The completed PDF will be downloaded to your device and securely emailed to info@gstelecom.com.au.