Konnekt-Telstra Captioning Videophone Program Agreement

clientID

Lead source description

Geo-automatic

Geo-IP Location

City State / Province / Region Country

Geo-IP Continent

Questions

Participation Agreement

The Konnekt-Telstra Captioning Videophone Program seeks to help Australians who have a severe or profound hearing impairment to stay connected.

This Program is available to customers already connected on one of Telstra’s phone networks.

Captioning Videophone User

Name of user

Residential address

Telstra phone number

Mobile (for text) (if any)

Work phone (if any)

Email Address (if any)

Current devices

Existing Internet service

Unknown - Please contact me regarding Internet
None, I have Telstra NBN voice only - please help me upgrade to Telstra NBN voice and data
None, I have a Telstra mobile phone service only - please supply Konnekt-managed mobile Internet
NBN Internet (data is already included in my plan)
Mobile Internet via my phone or tablet (unsuitable) - please supply Konnekt-managed mobile Internet
Mobile Internet via always-on 4G modem (suitable)
Other Internet

Existing Internet

Why my current device or regular phone is unsuitable

Additional Contact Person

(If it is easier for us to talk to someone you nominate)

Contact name

Phone

Email

Equipment Delivery

Deliver to

User
Additional Contact Person
Other

Contact name for delivery

Phone

Street address for courier

Instructions for courier

Conditions

All 4 check boxes must be ticked

Condition 1 - Details are accurate and correct*

I acknowledge that the details provided for the Captioning Videophone User are accurate and correct, and there is a need for the Captioning Videophone User to participate in the program.

Condition 2 - Program end and equipment care and return*

I acknowledge that the Program ends on 31 Dec 2022 unless otherwise advised in writing by Konnekt. I agree to take care of the equipment and return it if requested at the end of the Program or when my participation ends.

Condition 3 - Agree to Program fee and Telstra conditions*

I agree to pay Konnekt the Program Fee of $10 per month, or $5 per month if I already have a suitable Internet service, during my participation unless otherwise agreed with Konnekt. I understand that I must remain a Telstra customer, and if I currently have no compatible Internet service that Konnekt will assist me financially with a suitable Telstra Internet service.

Condition 4 - Feedback to Konnekt*

I agree that during the Program I may be asked to provide feedback to Konnekt in relation to the Konnekt service.

Privacy policy: konnekt.com.au/privacy Konnekt will only release the above information:

To Konnekt staff or contractors for purposes of equipment supply, connection, billing, on-going support, return, and to ask you about the Program to help us improve the Program; or
If we are required by law, or if required to obtain legal or accounting advice.

Legacy section with unused fields

Mounting Option - No additional cost

Table/bracket included.

Options

Heading field, hidden, for Installation options

Installation options

Only required for wall-mount (Videophone comes completely set up and personalized). Installation is available in most Australian metro/city centres.

Professional installation (Australia) AUD:

Phone number

A phone number for Videophone that your contacts can dial, on which to receive regular incoming phone calls. Please specify the area code.

Extras (per mth)

Hidden Extras field under which to list the Call Options.

Section with used fields

Payment Details

Payment method

Credit card or debit card
Electronic invoice I can pay by card or Paypal
Please contact me later about available payment options

I prefer to pay

Month-by-month
Every 3 months
Every 6 months
Annually

Payer name

Name on card

Card type

Card number

Expiry

CVC

Payer phone number

Payer email

Form Submission

This form is being submitted by

The Captioning Videophone user
An authorized representative

Authorized Representative

Authorized representative name

Relationship with user

Email address (for verification)

After you submit, Konnekt will immediately send you an email summary of your application. You must reply to our email to verify the submitter's email address.

What They Will buy Section

Incomplete and currently unused section because the decision about $5 vs $10, and KMM vs BYO vs Upgrade Telstra plan, can't be made until after a discussion or requesting the Telstra bill.

Order Date - dd/mm/yyyy

Payment Status text Part 1

Payment Status text Part 2

Once-off payment text

$5 fee text

$10 fee text

Monthly Fees Telstra part 1

Monthly Fees Telstra part 2

Monthly Fees Telstra part 3

Monthly Fees Telstra part 4

Internet subsidy yes

Internet subsidy no

Skype subscription text

Konnekt Mobile Internet yes

Konnekt Mobile Internet no

Last WTB text with modem

Last WTB text without modem

Comments about WTWB

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