Service Cancellation Form

Cancellation Application

Complete the cancellation details below. For enquiries, contact GS Telecom on 1300 667 303. This online form follows the sections of the existing GS Telecom Cancellation Application.

1. CRN

CRN / Account Number *

2. Customer Details

Company Name (if applicable)

ABN

Name *

Date of Birth

Driver's Licence No.

Postcode

Address *

Phone Number

Mobile Number *

Fax Number

E-mail Address

3. Cancellation Request Number

Enter each service number, requested cancellation date and service type.

a) Service Number

Request Date

Service Type

TelephoneInternet070 VOIPMobile

b) Service Number

Request Date

Service Type

TelephoneInternet070 VOIPMobile

c) Service Number

Request Date

Service Type

TelephoneInternet070 VOIPMobile

d) Service Number

Request Date

Service Type

TelephoneInternet070 VOIPMobile

4. Final Billing Address

Name

Payment Method

Address

Phone Number

Mobile Number

Fax Number

E-mail Address

5. Authorisation

I hereby authorize GS Telecom ABN 20 096 926 993 to debit my account fees. In the event of any changes to my monthly subscription fees, I authorize GS Telecom to debit the amount from the appropriate date in accordance with such changes.

6. Payment Method

Credit Card

Bank Direct Debit

Card Type

Credit Card Number

Expiry (MM/YY)

Card Holder's Name

Name of Bank / Institution

Account Name

BSB

Account Number

Authorised Signature *

Signature Date *

7. Customer Remarks

8. Declaration

I declare that the information provided on this form is true.

Authorised Signature of Applicant *

Date *

Declaration Remarks

The generated PDF is sent to info@gstelecom.com.au and saved to your device.