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HiBIS Update 7 Dec 2004 - Amendment of section 9.4
Notice under section 6 of the HiBIS Guidelines
Topic: Amendment of section 9.3 of the Guidelines Attachments
Details:
HiBIS Program Guidelines Attachments
9.4 Standard HiBIS provisions for the Customer application and attestation form
Delete existing section 9.4 of the Guidelines.
Replace with new section 9.4 of the Guidelines set out below. This amendment refines the capture of customer data and reflects the correct input sequence in HiBIS Online. It also includes provision for the capture of 'Office use only' information.
9.4 Standard HiBIS provisions for the Customer application and attestation form
Section 1: Applicant details
Residential applicant:
Title: Given names:
Surname:
Telephone (b/h): Telephone (a/h):
Mobile: Fax:
Email:
(Go to section 2)
Organisation applicant:
Small Business
Not-for-Profit organisation seeking a service for own use
Not-for-Profit organisation seeking a service to provide a public access facility
Indigenous Community Council
Organisation Name:
ABN: ACN: GST exempt: YES/NO
Number of full time employees: Number of public access points:
Contact details
Title: Given names:
Surname:
Position:
Telephone (b/h): Telephone (a/h):
Mobile: Fax:
Email:
Section 2: Address details
HiBIS Service Address:
(where the HiBIS service will be connected - must be a physical address i.e. cannot be a postal address)
Telephone number of Service Address:
Address Line 1:
Address Line 2:
Locality / Suburb: State: Postcode:
Postal Address:
(As Above, if same as Service Address)
Address Line 1:
Address Line 2:
Locality / Suburb: State: Postcode:
Physical Address:
(where you reside / address of your organisation-As Above, if same as Service Address)
Address Line 1:
Address Line 2:
Locality / Suburb: State: Postcode:
Previous provision of a HiBIS service to a particular HiBIS Premises.
In general, any given HiBIS Premises may have a HiBIS Service connected to it only once. However, where a HiBIS Customer stops receiving a HiBIS Service at a particular HiBIS Premises through circumstances beyond their control, the Customer may be eligible to be provided with another HiBIS Service at that Premises.
Have you or your organisation previously received a HiBIS service at the 'HiBIS Service Address' nominated above?
YES / NO
If YES, name of previous HiBIS service provider:
Reasons for terminating the service:
A second HiBIS Service may also be provided to a HiBIS Premises where a HiBIS Customer moves to that Premises and the HiBIS Service supplied to that Premises previously may no longer be supplied because of circumstances beyond the control of the customer. For example, the previous HiBIS customer at the address removed the satellite dish or wireless antenna when vacating the Premises.
To the best of your knowledge, has the HiBIS Premises nominated above been previously supplied with a HiBIS service but is no longer able to receive that HiBIS service?
YES / NO
If YES, name of previous HiBIS Provider (if known):
Reasons for the previous HiBIS service not being able to be supplied the address:
How did you hear about HiBIS?
Contact by Service Provider
Australian Government promotional material
(i.e. posters, radio, TV, Internet, newspapers etc;)
State/Local Government and/or community/industry organisations
Other - Please provide details:
I attest that, to the best of my knowledge:
· the personal information I have provided is true and accurate; and
· I, and the premises at which I require the HiBIS Service, are eligible under the Scheme and I have made such inquiries as are reasonable to confirm this.
I agree to:
· DCITA making inquiries as necessary with any organisation or individual to verify any information I have provided;
· my service provider making available to DCITA any information concerning my application and participation in HiBIS; and
· DCITA, as well as other Government agencies and/or my service provider using my personal information for the purposes of HiBIS program administration, evaluation, related policy development and other related functions.
I understand that:
· I may be required to provide documents to substantiate my attestation;
· I may be asked to participate in HiBIS evaluation activities; and
· it is a criminal offence under the Crimes Act 1914 to deliberately make false or misleading statements.
Signed by the customer: .......................................... Date: ..../..../....
Printed name: ...........................................
Section 3: Office Use Only
Name of service:
Incentive Rate: Telephone of Premises:
Reason why customer eligible:
Travel claim (if applicable):
Depot departed from: Distance Travelled:
Date service requested: Date of connection:
Date of claim: HiBIS Customer ID number: