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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 wireless modem/router can be used with up to four (4) wired computers and more than one hundred (100) multiple wireless connections. The wireless modem/router includes a one year warranty and can be purchased for $69.99... 6) If you require wireless service will you be purchasing a wireless modem/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? ______________________________________________________________________________ | ||||||||||||||||||||||||||||||||||||||||||
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Rev: 9/01/09
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