Optus requester name

Optus rep, account manager, product lead

First Name

Last Name

Optus Requester Email

Email address of Optus representative to receive customer facing SoW

Satellite Customer (organisation) Name

Organisation Name

Customer ABN

Optus Customer Number

Authorised signatory

Customer name to appear on the SoW for sign-off

First Name

Last Name

Delivery Address

Satellite hardware and/or SIMs to be sent to this address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Satellite Service Provider

Plan

Number of new services required

New services (plans) to be provisioned and numbers assigned

Hardware Required

Units Required

number of devices required

Special Instructions - Notes