Level 15, Corporate Centre One, 2 Corporate Court, Bundall, QLD, 4217
Dear Member,
If you wish to appoint an Authorised Representative or Advocate to deal with InfiNET Broadband us on your behalf, please:
If you require any assistance with this, please contact us.
Date:
To:
My account type/s (tick):
☐ Internet
☐ VoIP Phone
☐ Mobile
Account holder name (must be the actual account holder):
My account number:
Telephone number:
I wish to appoint either (tick one):
☐ an Authorised Representative; or
☐ an Advocate
The person I appoint (Full Name):
Their email address:
Their mobile number:
Their address is:
Limitation/s on authority of Authorised Representative/Advocate (Complete if applicable):
Time limits on appointment (complete if applicable):
I authorise you to deal with the above person as my Authorised Representative or Advocate. I acknowledge responsibility for anything my Authorised Representative or Advocate or does on my behalf within their authority as described in this Appointment. I release you from any claim I might otherwise have against you, based on anything you do in reliance on this Appointment. You may assume that you are dealing with the relevant person if they identify themselves as such when you contact any of the contact numbers / addresses above. The appointment continues until I revoke it in writing.
My signature:
Signature of witness:
Name of witness:
Qualification and address of witness (including registration details relating to witness qualification):
Doctor / Pharmacist / Lawyer / Police Officer (Please circle)
Confirmation by witness:
☐ I confirm that the person signing above has produced evidence of their identity.
