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| DATE: ________________ BILLING NUMBER: 503.845. _______ BROADBAND NUMBER: 503.845. _______ |
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| NAME: ___________________________________________________________________________________________ | |||||||||||||||||||||||||||||||||||||||||||||
| SERVICE ADDRESS: _______________________________________________________________________________ | |||||||||||||||||||||||||||||||||||||||||||||
| BILLING ADDRESS: _______________________________________________________________________________ | |||||||||||||||||||||||||||||||||||||||||||||
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Please
check the applicable BROADBAND INTERNET Service:
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Activation fee is $99.00. Activation fee is waived when customer commits to retain service for a minimum 12 month period. If service is disconnected for any reason during the 12 month commitment period, the installation charge will apply.
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I
understand and agree to the Terms and Conditions of the BROADBAND INTERNET
Service Agreement.
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PLEASE
ANSWER THE FOLLOWING QUESTIONS:
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1) DSL service for a desktop computer comes with a free modem. 2) How many telephones do you have on that line? ____ 3) Do you have any wall phone jacks? ____ Yes ____ No How Many? ____ 4) Does your computer have a NIC card? (Network Interface Card) ____ Yes ____ No 5) How many computers will you be hooking up to DSL? ____ For multiple computers, the Wi-Fi wireless router can be used with up to four (4) wired computers and more than one hundred (100) multiple wireless connections. The Wi-Fi wireless router can be leased for $3.95 month or purchased for $69.99. Purchase of router includes a one year warranty. 6) If you require wireless service will you be purchasing a Wi-Fi wireless router from Mt. Angel Telephone? ____Yes ____No 7) Do you have a telephone jack with dial tone at the location the DSL modem will be set? ____ Yes ____ No 8) For Static IP Address, what is the MAC Address of the equipment that will have the Static IP on it? 9) Does your business or residence have an alarm system? ____Yes ____No ______________________________________________________________________________ | |||||||||||||||||||||||||||||||||||||||||||||
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Rev: 01/03/11
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