Agent: UKT1063

APPLICATION FORM FOR FRANCE
Telephone and Internet Services
PLEASE COMPLETE/SIGN & RETURN BY POST TO
UK Telecom Ltd
Media House
The Lansbury Estate
Knaphill Woking Surrey
GU21 2EP
United Kingdom
Tel +44 1483 833 795 or Fax to: +44(0)1483 833 794
French Freephone number: 0800 940 614
Please keep a copy for your records
Customer Details/Installation Address
Agent: UKT1063
Telephone Services Options:
Please select one of the following:
Pay as you go
Unlimited Anglo landlines (19.90€)
Unlimited landlines 53 destinations (37€)
Broadband Services:
€29.50 + €3.00 for WIFI Modem* (Service requires FT Line)
Please select one of the following
Name
Address
Country
Post Code
Tel No 1
Tel No 2
Fax No
email
€19.00 Unlimited
Optional Call Plans (only available with B/Band)
Unlimited Calls to landlines in Australia, Canada, Ireland,
UK, USA and France €9.99
*€3.00 for Modem is not charged if in Degroupage Area
Current Telephone Provider
DECLARATION
I confirm that I am the holder of the Telephone Line stated. I hereby
give UK Telecom the right to route my calls from the telephone line
stated and also internet services if requested and agree to the
Terms & Conditions (enclosed).
Current Broadband Provider
We hereby authorize UKTelecom to debit my account using Direct
Debit/Prelevement 14 days after invoice date.
(NB Please ensure you cancel your existing contract in writing)
Please note that if our Telephone Service is not selected then
this will be automatically added to your service. In the event
you do not wish to have this option please note there will be
an additional charge of €7.50 to your Broadband Fee.
Signature
Date
AUTORISATION DE PRELEVEMENT (Joindre obligatoirement un RIB/enclosed the mandatory RIB) (Relevé d’Identité Bancaire)
No National d’Emetteur 517683
Nom et adresse de l’éstablissement bancaire
Name and address of the bank or postal account
Nom et adresse postale du titulaire du compte à débitter
Name and address of account holder
Compte à débiter
Account to Debit (as shown on your RIB or Bank statement)
Code Etab
Signature du titulaire du compte
Signature of account holder
Date
Numéro de Compte
Guichet
Clé RIB
J’autorise l’Etablissement teneur de mon compte à prélever sur ce demier, si
la situation le permet, tous les prélèvements ordonnés par le créancier désigné
cidessous. En cas de litige sur un prélèvement, je pourrai en faire suspender
l’exécution par simple demande à l’ Etablissement teneur de mon compte.
Je réglerai le différend d directement avec le créancier.