PortNET
Locked Bag 1818
Wynnum
Q4178

Dear Customer,

If you wish to appoint an Advocate or Authorised Representative to deal with us on your behalf, please:

• Carefully read the important notes below;
• Carefully complete the form on the next page;
• take it, with some proof of your identity, to a witness as indicated next;
• sign it in the presence of a lawyer or doctor or pharmacist or Centrelink officer or member of police as witness; and
• post it to us at the address above.

Important notes:

1. What is an Advocate?
An ‘Advocate’ you appoint can deal with us on your behalf (including making a complaint) but:
(a) Cannot change your account or services; and
(b) Cannot act on your behalf or access your information unless you are present and agree.

2. What is an Authorised Representative?
An ‘Authorised Representative’ you appoint can deal with us on your behalf as your agent (including making a complaint) and:
(a) if you give them limited rights: has only those rights including any limitations you specify on access to your information; and
(b) If you do not give them limited rights: has power to act and access information as if they are you.

3. If we are not clear whether you intend to appoint an Advocate or an Authorised Representative, we will assume you only intend to appoint an Advocate.

4. We may also accept a person who holds an appropriate Power of Attorney or Guardianship Order as Advocate or Authorised Representative for a customer. Please forward a certified copy of the Power of Attorney or Guardianship Order together with this form (signed by the Attorney or Guardian for the customer). We may need to have the documents checked before we can accept the appointment.

5. To protect your privacy and security and to minimise the risk of fraud, our requirement is that this Appointment be submitted by post as a signed original, witnessed by a lawyer or doctor or pharmacist or Centrelink officer or member of police.

Appointment of Advocate Or Authorised Representative

To:   PortNET Date: ______________________

My account type:   Internet My Debtor ID: ______________

Account holder name: _________________________________________________________
Note: This must be the actual account holder.

I wish to appoint either: an Advocate
  (tick one) or an Authorised Representative

The person I appoint is: _______________________________________________________

Their email address is: ________________________________________________________

Their landline number is: ______________________________________________________

Their mobile number is: _______________________________________________________

Their physical address is: _____________________________________________________

Limitation/s on authority of Authorised Representative: ________________________

_______________________________________________________________________________
(Complete if applicable)

My appointment and authority:
I authorise you to deal with the above person as my Advocate or Authorised Representative (as applicable). I acknowledge responsibility for anything my Advocate or Authorised Representative does on my behalf within their authority as described in this Appointment. I release you from any claim I might otherwise have against you, based on anything you do in reliance on this Appointment. You may assume that you are dealing with the relevant person if they identify themselves as such when you contact any of the contact numbers / addresses above. The appointment continues until I revoke it in writing.

My signature: _________________________________________________________________

Witness Signature: ____________________________________________________________

Witness Name: ________________________________________________________________

Witness Qualification: _________________________________________________________
Lawyer / doctor / pharmacist / Centrelink officer / police

Witness Address: ______________________________________________________________

Confirmation by witness: I confirm that the person signing above has produced evidence of their identity.