KEY CUSTOMER ACTIVATION FORM
/Please complete form in capital / block letters only and fax to Xantic Customer Services in Australia on FaxNumber +61 7 5498 0098 For assistance with this form: Phone Number +61 7 5498 0000
Inmarsat GAN Terminal / GAN SIM Card (v1.1)
This form is only to be used when the applicable Inmarsat Terms and Conditions have been signed by the Subscriber and are held by Xantic Customer Service.
1. Subscriber Details
/2. Terminal / SIM Type
Name
/Terminal
/SIM Card
Address
/Terminal & SIM Card
Town/City
/State/Province
3. Environment Usage
Country
/Post/Zipcode
/Land
Phone Number
/Fax Number
4. Installation Type
Email Address
/Mobile
/Fixed
Contact Name
5. Primary Use
Government
Transport
Media
/Security
Finance
Tourism
/Humanitarian
Construction
Agents
/Rental
Energy
Agriculture
/Mining
Other
6. Submitter Contact Details (If different from Section 1)
Contact Name
Phone Number
12. Service Details
Email Address
/Quan
/Privacy
/Service
/Existing IMNs to be assigned
Voice 4.8Kb
/7
/6
7. Subscriber Xantic Account Details
Account Manager
/Fax 2.4Kb
/7
/6
Direct Invoicing
/Yes (Complete Below)
/No
/Data 2.4Kb
/7
/6
Account Number
/Terminal/SIM card must be billed to an existing account
/ISDN Data 64K
/6
/0
VAT (EU Only)
/ISDN Data 56K
/6
/0
ISDN 64K Audio 3.1Khz
/6
/0
8. Subscriber Invoice Address (If different from Section 1)
Name
/ISDN 64K Speech
/6
/0
Address
/MPDS Data
/6
/0
Town/City
/By default and unless otherwise directed each GAN Terminal/SIM Card will be activated with 2 voice channels and 1 of each other channel available.
State/Province
/ MPDS Username /Username can be 6-15 characters. Only letters, numbers, dot & underscore
Country
/Post/Zipcode
/ MPDS Password9. MES (Mobile Earth Station)
/13. SIM Serial Numbers (SSN)
Country of Registry
/Country of Registry
Manufacturer
/SIM Serial No. 1
/8
/0
Model
/SIM Serial No. 2
/8
/0
MES Serial Number
/7
/6
/SIM Serial No. 3
/8
/0
SIM Serial No. 4
/8
/0
10. Accounting Authority or ISP ( Select One Only)
AAIC
/NL01
/AA07
/Other
/SIM Serial No. 5
/8
/0
ISP
/8012
/8020
/Other
/If more than 5 SIM cards are required please submit additional forms.
8025
/8026
/8026 Terminal & 8012SIM
14. Subscriber Declaration
Note: 8012, 8020 In & Outbound Calling / 8025 Prepaid / 8026 Receive calls only. The subscriber must first obtain agreement and provide proof from the nominated AAIC/ISP that the billing entity accepts the charges for the nominated service/s.
/ By signing this Key Customer Activation Form I hereby declare that I have previously signed a valid Terms and Conditions for Inmarsat agreement with Xantic, and Iagree that this Key CustomerForm shall become an annex to that agreement.Name
11. Additional Information
Please write any additional instructions for this activation request.
/ Date Signed / Thursday, 12 February 2004Date Activation Requested / Signature:
12/02/2004