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Agent Code
Agent Name
Zebra Customer ID (existing customers only)

Details of the line owner

Title		*First Name	*Surname
*Date of Birth		*Phone Number	Fax Number
Mobile Number		*Email Address
*Street Address			State and Postcode

Driver's Licence Medicare Number	Number:

Billing Address (Enter only if different from above)
Street Address			State and Postcode

Please tell us how you heard about Zebra:

Long Distance Calls Only

Please provide phone numbers you wish to connect to Zebra Long Distance Call Service

Calls service only: Telephone Numbers:
	Override	Preselect
	Override	Preselect
	Override	Preselect

Home Phone Plans

Select a plan

Provide the phone number/s you want to transfer to Zebra. (Note: Your phone number must remain active before and during transfer.) For more information on Zebra Plans click here.

Phone Number
Phone Number
Phone Number
Phone Number
	I want to have a new phone number allocated (charges apply)
Who currently bills you for your line rental and local calls?
	Telstra
	Other (please specify)

Mobile Phone Plans

Select a plan

Provide the phone number/s you want to transfer to Zebra.(Note: Your phone number must remain active before and during transfer.)

Mobile Number
Mobile Number
Mobile Number
Mobile Number
	I want to have a new phone number allocated
	I want to order a new handset
	I want to use my existing Zebra mobile number
	I want to port my mobile number from another provider
Account Number/s: ( previous carrier )

Authorisation

*	I ACKNOWLEDGE THAT I HAVE READ TERMS AND CONDITIONS IN FULL AND I ACCEPT THEM.

* required field