myhomefone Order Form

Order Form

Please fill in the form below.
I'm ordering:*
Title*
Name*

First NameLast Name
DOB*

DayMonthYear
Date
Phone Number*

Area CodePhone/Mobile Number
Address*

Street Address

Street Address Line 2

SuburbState

Post CodeCountry
E-mail
Deliver to this address*

YesSend to different address
Delivery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Customer Type*
Company Name
Seniors/Pension Card Number
(If applicable)
ABN Number*
Do you wish to divert your existing landline number?*

YesNo
Landline Number
Please provide details of your current landline provider. Please ensure this information is correct, it is necessary to port your old number successfully.
Current Provider*
Account Number*
Would you like a new landline number?*
If you do not wish to divert a new landline number, incoming callers will be charged at standard mobile rates.
Professional Monitoring?*

YesNo
Speed Dial Number 1 (M1 button)*
For Communicator Memory Numbers
Speed Dial Number 2 (M2 button)*
For Communicator Memory Numbers
Contact Person 1

First NameLast Name
Phone Number
Relationship*
Contact Person 2

First NameLast Name
Phone Number
Relationship*
Contact Person 3

First NameLast Name
Phone Number
Relationship
Contact Person 4

First NameLast Name
Phone Number
Relationship
Medical Notes
Response Instructions/General Notes
myhomefone 4G Setup Costs

$99 setup fee
myhomefone Monthly Costs*

UNLIMITED Phone Only - $35 per monthUNLIMITED + 18GB - $45UNLIMITED + 30GB - $55
Personal Security Communicator Costs

$49.95 setup fee$25 per month
Combo Costs

$99 setup fee$64.95 per month
Professional Monitoring Cost

$22 per month
New Landline Number

$24.95 setup fee
To finalise your order and set up Direct Debit, please call 1300 031 107 during business hours (Mon-Fri 9am-4pm)
How did you hear about myhomefone?*
Promo Code
Signature*

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