SERVICE APPLICATION FORM
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1 SERVICE APPLICATION FORM Remark Contract number CUSTOMER INFORMATION Private person Legal entity Name: Contact Phone: Last name: Contact cell phone: Company: Street, street number and floor: City and postal number: address: Personal identification number: Installation address: BILLING ADDRESS (If different from customer address) Name and Last name / Company: City and postal number: Street, street number and floor: I expressly declare that my personal identification number (PIN) and other personal information are made available to Intersat Telecommunications Ltd. I give consent to Intersat Telecommunications Ltd. so that my personal data may be used for their own purposes, and that it may be collected, processed, edited and exchanged, which includes forwarding to third parties in all by-law defined cases. INVOICE BY Mail E-BOX INTERNET AND VOICE SERVICES SPEED up to 10/2 Mbps DATA PACKAGE 8 GB SPEED up to 10/2 Mbps DATA PACKAGE 16 GB SPEED up to 22/6 Mbps DATA PACKAGE 25 GB SPEED up to 22/6 Mbps DATA PACKAGE 100 GB UNLIMITED TRAFFIC FROM 00H TO 6H Equipment rental Satellite set 90,00 kn* Wi-Fi router 10,00 kn* VoIP service * List price with VAT included (Includes VoIP device rental) VoIP one time activation fee 199,99 kn* Monthly fee for VoIP service 15,00 kn* (free for Intersat Tooway service users) INSTALLATION Without commitment period 12 months commitment 24 months commitment * List price with VAT included CONTRACTOR INFORMATION SUBSCRIBER INFORMATION A user who has concluded the contract away from Operators business premises has the right to terminate the subscriber contract by submitting a written and signed statement of cancellation to the Operator within 14 (fourteen) working days from the date of signing the Application, and in that case he will not be charged the subscription fees for early termination. The contract for the selected service shall be concluded for an indefinite period with or without a minimum commitment period of the contract. In the event of termination prior to the expiration of the commitment period of the contract Intersat has the right to claim compensation for early termination in accordance with the price list. The deadline for the activation of contracted services is 45 days from the date of acceptance of the Application by Intersat Telecom. In the case of complaint about Internet access speed it is required to perform a measurement of access speed via tools available on My signature confirms delivery and availability of Intersat Telecoms General Terms and Conditions, that I'm familiar with them and that I accept them fully. Employee: Code: City: Postal office code: Date: Postal office: Subscriber signature: Employee signature:
2 ZAHTJEV ZA PRUŽANJE USLUGE Napomena Broj ugovora PODACI O PRETPLATNIKU/PRIKLJUČKU Fizička osoba Pravna osoba Ime: Kontakt telefon: Prezime: Kontakt mobitel: Tvrtka: adresa: Ulica, kućni broj i kat: OIB: Adresa priključka: ADRESA ZA SLANJE RAČUNA (ako je drugačija od adrese platežno odgovorne osobe) Ime i prezime / Naziv tvrtke: Ulica i kućni broj: Izričito izjavljujem da sam tvrtki Intersat telekomunikacije d.o.o. dobrovoljno stavio/la na raspolaganje svoj osobni identifikacijski broj (0IB) i ostale osobne podatke. Dajem pristanak Intersat telekomunikacijama d.o.o. da se mojim osobnim podacima može koristiti za vlastite potrebe, odnosno da iste može prikupljati, obrađivati i razmijenjivati, što uključuje i proslijeđivanje podataka trećim osobama, u svim zakonom predviđenim slučajevima. SLANJE RAČUNA Poštom E-BOX om INTERNET I GOVORNE USLUGE PAKET PROMETA 8 GB PAKET PROMETA 16 GB PAKET PROMETA 25 GB PAKET PROMETA 100 GB PROMET od 00h do 6h NEOGRANIČEN Najam opreme Satelitski komplet 90,00 kn* Wi-Fi router 10,00 kn* Sezonska opcija* *Naplata usluge minimalno 6 mjeseci neprekinuto unutar godinu dana. Preostali period se naplaćuje samo najam opreme. Nakon aktivacije ponovno minimalni period od 6 mjeseci neprekinutog korištenja usluge. VoIP govorna usluga (uključuje najam VoIP uređaja) jednokratna aktivacija VoIP govorne usluge 199,99 kn* mjesečna naknada za VoIP govornu uslugu 15,00 kn* (besplatno za korisnike Intersat Tooway paketa usluga) PRIKLJUČENJE Bez ugovorne obveze 12 mjeseci 24 mjeseca 4. PODACI O UGOVARATELJU 5. PODACI O PRETPLATNIKU Korisnik koji je ugovor sklopio izvan poslovnih prostorija Operatora ima pravo raskinuti pretplatnički ugovor dostavljanjem Operatoru vlastoručno potpisane izjave Korisnika o raskidu u roku od 14 (četrnaest) radnih dana od dana potpisa Zahtjeva te mu u tom slučaju neće biti naplaćena pretplatnička naknada za prijevremeni raskid. Ugovor za odabranu uslugu sklapa se na neodređeno vrijeme uz ili bez razdoblja obveze minimalnog trajanja ugovora. U slučaju raskida ugovora prije isteka obveznog trajanja Intersat ima pravo potraživati naknade za prijevremeni raskid sukladno Cjeniku usluga. Rok za aktivaciju ugovorene usluge je 45 dana od dana prihvaćanja zahtjeva od strane Intersat Telecoma. U slučaju reklamacije na brzinu usluge pristupa internetu obvezna je provedba mjerenja pristupne brzine putem alata dostupnog na Svojim potpisom potvrđujem da su mi uručeni i učinjeni dostupnima Opći uvjeti poslovanja Intersat Telecoma, da sam sa istima upoznat te da ih u cijelosti prihvaćam. Djelatnik: Šifra: Mjesto: Šifra poštanskog ureda: Datum: Naziv poštanskog ureda: Potpis Pretplatnika: Potpis djelatnika:
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4 ZAHTJEV ZA PRUŽANJE USLUGE Napomena Broj ugovora PODACI O PRETPLATNIKU/PRIKLJUČKU Fizička osoba Pravna osoba Ime: Kontakt telefon: Prezime: Kontakt mobitel: Tvrtka: adresa: Ulica, kućni broj i kat: OIB: Adresa priključka: ADRESA ZA SLANJE RAČUNA (ako je drugačija od adrese platežno odgovorne osobe) Ime i prezime / Naziv tvrtke: Ulica i kućni broj: Izričito izjavljujem da sam tvrtki Intersat telekomunikacije d.o.o. dobrovoljno stavio/la na raspolaganje svoj osobni identifikacijski broj (0IB) i ostale osobne podatke. Dajem pristanak Intersat telekomunikacijama d.o.o. da se mojim osobnim podacima može koristiti za vlastite potrebe, odnosno da iste može prikupljati, obrađivati i razmijenjivati, što uključuje i proslijeđivanje podataka trećim osobama, u svim zakonom predviđenim slučajevima. SLANJE RAČUNA Poštom E-BOX om INTERNET I GOVORNE USLUGE PAKET PROMETA 8 GB PAKET PROMETA 16 GB PAKET PROMETA 25 GB PAKET PROMETA 100 GB PROMET od 00h do 6h NEOGRANIČEN Najam opreme Satelitski komplet 90,00 kn* Wi-Fi router 10,00 kn* Sezonska opcija* *Naplata usluge minimalno 6 mjeseci neprekinuto unutar godinu dana. Preostali period se naplaćuje samo najam opreme. Nakon aktivacije ponovno minimalni period od 6 mjeseci neprekinutog korištenja usluge. VoIP govorna usluga (uključuje najam VoIP uređaja) jednokratna aktivacija VoIP govorne usluge 199,99 kn* mjesečna naknada za VoIP govornu uslugu 15,00 kn* (besplatno za korisnike Intersat Tooway paketa usluga) PRIKLJUČENJE Bez ugovorne obveze 12 mjeseci 24 mjeseca 4. PODACI O UGOVARATELJU 5. PODACI O PRETPLATNIKU Korisnik koji je ugovor sklopio izvan poslovnih prostorija Operatora ima pravo raskinuti pretplatnički ugovor dostavljanjem Operatoru vlastoručno potpisane izjave Korisnika o raskidu u roku od 14 (četrnaest) radnih dana od dana potpisa Zahtjeva te mu u tom slučaju neće biti naplaćena pretplatnička naknada za prijevremeni raskid. Ugovor za odabranu uslugu sklapa se na neodređeno vrijeme uz ili bez razdoblja obveze minimalnog trajanja ugovora. U slučaju raskida ugovora prije isteka obveznog trajanja Intersat ima pravo potraživati naknade za prijevremeni raskid sukladno Cjeniku usluga. Rok za aktivaciju ugovorene usluge je 45 dana od dana prihvaćanja zahtjeva od strane Intersat Telecoma. U slučaju reklamacije na brzinu usluge pristupa internetu obvezna je provedba mjerenja pristupne brzine putem alata dostupnog na Svojim potpisom potvrđujem da su mi uručeni i učinjeni dostupnima Opći uvjeti poslovanja Intersat Telecoma, da sam sa istima upoznat te da ih u cijelosti prihvaćam. Djelatnik: Šifra: Mjesto: Šifra poštanskog ureda: Datum: Naziv poštanskog ureda: Potpis Pretplatnika: Potpis djelatnika:
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