If you wish to appoint an Authorised Representative to deal with Datawave Internet Pty Ltd
on your behalf, please complete the form below.Please note
When you appoint an Authorised Representative you are giving the person you appoint the
authority to deal with us on your behalf as your agent. This means that the Authorised
Representative has the power to act and access information as if they were you. This
includes making complaints, changing account details or terminating a contract. You can of
course specify limitations of your Authorised Representative’s rights.
Please note that only account holders can appoint an Authorised Representative. If you wish
to appoint more than one Authorised Representative, please complete one Authorised
Representative Form for each person you wish to appoint. You can appoint up to three
Authorised Representatives.
For security reasons we require you to submit the completed Authorised Representative
Form to us as a signed original and witnessed by one of the following persons below:
A Justice of the Peace;
An Accountant who is a member of the Australian Institute of Chartered Accountants,
CPA Australia or the National Institute of Accountants with 2 or more years of
continuous membership;
A Solicitor or Barrister;
A Police Officer;
An agent in charge of, or a permanent employee (with 2 or more years of continuous
service) of an Australia Post outlet;
An officer with, or authorised representative of, a holder of an Australian Financial
Services Licence, having 2 or more continuous years of service with one or more
licensees;
A Dentist;
A Pharmacist;
A Medical Practitioner;
A Chiropractor or a Physiotherapist.
Please contact us on 07 4168 5789 if this proves too difficult or inconvenient for you, and
we will work with you to find an alternative way of appointing an Authorised Representative.
Appointment of Authorised Representative
Your details:
Account number:
___________________________________________________________________
Account holder’s full name (note: you must be the account holder to appoint an Authorised
Representative):
___________________________________________________________________
“I wish to appoint the following person as my Authorised Representative”:
Your Authorised Representative’s details
Authorised Representative’s full name:
____________________________________________________________________
Authorised Representative’s telephone number:
____________________________________________________________________
Authorised Representative’s email address (if applicable):
____________________________________________________________________
Authorised Representative’s physical address:
____________________________________________________________________
Limitations of the Authorised Representative’s rights (Specify anything that your Authorised
Representative should NOT be allowed to do on your behalf. If left blank, the Authorised
Representative has the power to act as if they were you.):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Appointment declaration:
“I, ___________________________________________________, authorise Datawave Internet Pty Ltd
to deal with the above person as my Authorised Representative. I acknowledge that I am
responsible for all acts of my Authorised Representative within the authority as described in
this Appointment. Datawave Internet Pty Ltd may assume that it is dealing with the
Authorised Representative if they identify themselves as such when contacted at any of the
contact numbers/addresses above. This appointment continues until I revoke it in writing.”
Signature:
Place and date:
____________________________________________________________________
Account holder’s signature:
____________________________________________________________________
Witness’s declaration and signature:
“I confirm that the person signing above (account holder) has produced evidence of their
identity.”
Place and date:
____________________________________________________________________
Witness’s signature:
____________________________________________________________________
Witness’s full name:
____________________________________________________________________
Witness’s capacity (JP, police officer etc.) and address:
____________________________________________________________________
____________________________________________________________________
on your behalf, please complete the form below.Please note
When you appoint an Authorised Representative you are giving the person you appoint the
authority to deal with us on your behalf as your agent. This means that the Authorised
Representative has the power to act and access information as if they were you. This
includes making complaints, changing account details or terminating a contract. You can of
course specify limitations of your Authorised Representative’s rights.
Please note that only account holders can appoint an Authorised Representative. If you wish
to appoint more than one Authorised Representative, please complete one Authorised
Representative Form for each person you wish to appoint. You can appoint up to three
Authorised Representatives.
For security reasons we require you to submit the completed Authorised Representative
Form to us as a signed original and witnessed by one of the following persons below:
A Justice of the Peace;
An Accountant who is a member of the Australian Institute of Chartered Accountants,
CPA Australia or the National Institute of Accountants with 2 or more years of
continuous membership;
A Solicitor or Barrister;
A Police Officer;
An agent in charge of, or a permanent employee (with 2 or more years of continuous
service) of an Australia Post outlet;
An officer with, or authorised representative of, a holder of an Australian Financial
Services Licence, having 2 or more continuous years of service with one or more
licensees;
A Dentist;
A Pharmacist;
A Medical Practitioner;
A Chiropractor or a Physiotherapist.
Please contact us on 07 4168 5789 if this proves too difficult or inconvenient for you, and
we will work with you to find an alternative way of appointing an Authorised Representative.
Appointment of Authorised Representative
Your details:
Account number:
___________________________________________________________________
Account holder’s full name (note: you must be the account holder to appoint an Authorised
Representative):
___________________________________________________________________
“I wish to appoint the following person as my Authorised Representative”:
Your Authorised Representative’s details
Authorised Representative’s full name:
____________________________________________________________________
Authorised Representative’s telephone number:
____________________________________________________________________
Authorised Representative’s email address (if applicable):
____________________________________________________________________
Authorised Representative’s physical address:
____________________________________________________________________
Limitations of the Authorised Representative’s rights (Specify anything that your Authorised
Representative should NOT be allowed to do on your behalf. If left blank, the Authorised
Representative has the power to act as if they were you.):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Appointment declaration:
“I, ___________________________________________________, authorise Datawave Internet Pty Ltd
to deal with the above person as my Authorised Representative. I acknowledge that I am
responsible for all acts of my Authorised Representative within the authority as described in
this Appointment. Datawave Internet Pty Ltd may assume that it is dealing with the
Authorised Representative if they identify themselves as such when contacted at any of the
contact numbers/addresses above. This appointment continues until I revoke it in writing.”
Signature:
Place and date:
____________________________________________________________________
Account holder’s signature:
____________________________________________________________________
Witness’s declaration and signature:
“I confirm that the person signing above (account holder) has produced evidence of their
identity.”
Place and date:
____________________________________________________________________
Witness’s signature:
____________________________________________________________________
Witness’s full name:
____________________________________________________________________
Witness’s capacity (JP, police officer etc.) and address:
____________________________________________________________________
____________________________________________________________________