LETTER OF AUTHORITY

I authorise Service Broker to deal with the provider named below about my account, only as ticked, for the time shown.

1. ME (THE ACCOUNT HOLDER)
Your name: ________________________________________
Business name (if any): ________________________________________
ABN (if any): ________________________________________
Address: ________________________________________
Phone and email: ________________________________________

2. THE PROVIDER
Provider name: ________________________________________
Account number(s): ________________________________________
Name and date of birth or other ID the provider may ask for (optional): ________________________________________

3. AUTHORISED REPRESENTATIVE
Colin Dixon trading as Service Broker, ABN 68 758 286 944, Mallacoota VIC 3892. Phone 0419 415 000, email help@servicebroker.com.au.

4. WHAT SERVICE BROKER MAY DO (tick each box that applies)
[ ] Enquire about my account and get information: bills, plans, usage, contract terms and end dates.
[ ] Negotiate prices, plans and fees, and dispute or query charges (for example over-billing).
[ ] Request changes to my plans or services that I have approved.
[ ] Agree to a new contract on my behalf (only if ticked).
[ ] Make payments on my behalf (only if ticked).

Unless the last two boxes are ticked, this letter does NOT allow Service Broker to sign or agree to a new contract, or to make any payment, for me.

5. HOW LONG
This authority starts on the date signed and lasts for 6 months (or ____ months), unless I cancel it earlier. I can cancel it at any time by telling the provider and Service Broker in writing.

Service Broker will use information from the provider only for this work, and handle it as set out at servicebroker.com.au/privacy.

6. SIGNED
Signature: ________________________________________
Name: ________________________________________
Position (if signing for a business): ________________________________________
Date: ________________________________________

Note: Some providers require their own authority form. If so, we'll send it to you to sign instead of, or as well as, this one.