Personal Emergency Response Systems 4G Personal Emergency Response System * Indicates Required Fields PLEASE COMPLETE THE FOLLOWING FORM AND WE WILL RESPOND PROMPTLY.*4G EQUIPMENT OPTION* NEVERALONE 4G Pendant $490 ex GST TWIG One 4G Handset $990 ex GST TWIG One 4G Ex Handset $1390 ex GST QUANTITY REQUIRED?Confirm the quantity of units required?Recurring Monitoring Period?* 3 Monthly 6 Monthly 12 Monthly *NEVERALONE 4G MONITORING* BASIC Panic Only Monitoring $10 + GST Wk PREMIUM Panic Monitoring + 2 Way Voice + GPS Location Tracking $12 ex GST Wk Monitoring services include 4G SIM Card and data communication costs.*TWIG 4G MONITORING* BASIC Panic with GPS Location Only $10 + GST Wk PREMIUM Panic + 2 Way Voice + GPS Location + Tracking $12 ex GST Wk Client to provide suitable 4G SIM and Service*NEW SERVICE CONNECTION* 4G CONNECTION + PROGRAMMING + TESTING + DELIVERY $140 + GST Standard delivery and installations charges allowed for Adelaide Metropolitan area. NOTE: Installation outside metro area may attract additional charges. OPTIONAL EXTRAS?Please provide a detailed description of any optional extras required with your order.CUSTOMER DETAILSClient/Account Name?*Service/Device User Name?*Client/User Phone*The phone number of the individual that relates to the portable emergency response unit. EG: Mobile for portable device premises landline for base station equipment.Service Contact Email* Client/Account Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country SPECIAL REQUIREMENTS?Describe any special requirement that may affect the operation of this PERS equipment or Service? REMOTE MONITORING - NOMINATED CONTACTSThe following section is the Nominated Contacts for clients with Remote Monitoring and Tracking services activated. *Voice ID Code*The Voice ID Code is utilised to identify the user for safety and security reasons. NOTE: Use a secret word (min 3+ letters) in combination with a secret number (min 3+ numerals)1. *Nominated Contact*Contact Name:Primary Ph:Secondary Ph: Add Remove 2. Nominated ContactContact Name:Primary Ph:Secondary Ph: Add Remove 3. Nominated ContactContact Name:Primary Ph:Secondary Ph: Add Remove 4. Nominated ContactContact Name:Primary Ph:Secondary Ph: Add Remove *IMPORTANT NOTE:* I have read and acknowledge the following IMPORTANT NOTICE..1. A Premises Voice Identification Code is required for all persons that will be contacts for the security relating to this service, to identify themselves when communicating with our VIP Monitoring Centre. You can share the Voice ID or individuals can have individual ID’s (Recommend a Minimum combination of 2 or 3 Numbers with 2 or 3 letters (EG: AGD-001). Please avoid using birthdays and premises numbers for voice codes as they are too easy to guess. 2. Nominated Contacts in the event of an Alarm condition. We recommend that if you are responsible for taking control of the service's security, you should be listed as the 1st contact for the service and provide your after hours details. If applicable, you will also need to provide us with the contact names and numbers of other nominated after hours contacts, including the details of their after hours phone numbers. We suggest at least 2 in order of priority including yourself. 3. IMPORTANT NUMBERS TO NOTE Please save the following phone numbers in all Emergency After-hours contacts phones. 4. MSE Alarms (08) 8235 1001 – Office number to call for any billing queries, service during office hours or transfer to Emergency Technical support, available after-hours (follow the prompts). 5. Monitoring Centre - Contacts 1300 300 823 – If you need to contact the monitoring centre regarding testing your system or following an alarm (accidental activation etc). You will need to have your Voice code ready for the MSE VIP staff to identify you. 6. MSE Monitoring Centre - Caller ID (07) 3722 8990 & (02) 8879 4090 – We recommend that you save these numbers into your mobile phone, so you easily identify that the monitoring centre is calling you. Do not call back on this number as you will only receive a recorded message. *Consent to MSE Terms of Trade* I have read and agree to MSE Terms of TradeI have read and accept the following: MSE Security P/L T/A MSE Alarms Terms of Trade 1st Oct 2013 COPY HERE https://www.msealarms.com.au/customer-service/terms-of-trade/ PAYMENT OPTIONS*Customer Account Type*CREDIT CARD AUTHORITY - Complete Details BelowFULLY INVOICE IN ADVANCE - Payment Before Commencing WorksEXISTING CREDIT ACCOUNT CUSTOMERNOTE: Invoiced Customers consent to additional charges for late payment in accordance with MSE T.O.T.Credit Card Authorisation I agree to this Credit Card AuthorisationI the cardholder declare all information provided on this form to be true and complete. I acknowledge and agree that I authorise MSE Security Pty Ltd T/A MSE Alarms, to debit the credit card account nominated for all future invoices as they become payable until advised otherwise in writing.Credit Card Cardholder Name Card Details PLEASE NOTE: On submission of this form a $1.00 charge will be applied to your credit card and subsequently applied to your account.Initial Deposit As A CreditPhoneThis field is for validation purposes and should be left unchanged.
