Broadband Value Plan APplication Click Here to Download Application Applicant Name Applicant Cell #Driver's License Number StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDOB Month Day Year FEIN # (Business Only) Federal Employer Identification NumberContact Name Contact Cell #Service Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Township Mailing Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Login Name Preferred Email Address Local Telephone + Long Distance + Broadband Value Plan $86.00 / 300 min Long Distance FREE/ 30 Mbps Broadband Unlimited Classic Plan $96.00 / 500 min Long Distance FREE / 30 Mbps Broadband Unlimited Ultimate Plan $106.00 / 1,000 min Long Distance FREE/ 30 Mbps Broadband Unlimited Copper 2 Mbps, where Fiber is Not available, plan price stays same. Upgrade option to 50 Mbps is an additional monthly fee of $20.00 per month (estimated plan prices, taxes & fees may vary)All plans below come with Free Extended Community Calling if with Sirentel *Installation Fee $99.00Wireless Router Option D-Link Dual Band Smart (DIR-AC1750) Wireless Router, Onetime Fee $121.00 ZyXel Dual Band Wireless Router WiFi 6(EX3510 AX5700 Gigabit Ethernet) Onetime Fee $176.00 Wireless router not purchased from Sirentel $32.00 programming fee Static IP Address $10.00 per month (The following items may require a Static IP: Security Cameras & VPN’s) Customer Has Own Wireless Router, Customer Will Program (No Charge) *Router purchased from Sirentel has 1 year limited warranty.Wireless Router Password (Must be 8 letters, no more than 12)Name for Wireless Router (or we will default to My Network)Router Admin Password (To secure your router settings)Switch Long Distance to Sirentel Has Sirentel Long Distance Wants No Long Distance ECC Calling Only *Customer Must Contact Long Distance Provider to Cancel Service Included with Each Plan Call ID Number Call Waiting Three Way Calling Call Forwarding Selective Call Rejection Selective Call Acceptance I, the undersigned, am requesting a Siren Telephone’s Internet Account. By signing the agreement, I agree to the terms and conditions detailed in the policies found on Siren Telephone’s website, http://www.sirentel.com There is a monthly modem maintenance fee of $4.75, which covers the repair and/or replacement of the modem. Upon termination of Broadband service, the modem must be returned to the Siren Telephone’s business office or a $172.95 charge will be assessed. A $99.00 charge for early termination plus number of months left of 6-month connection will be accessed. Fiber modem stays at residence. Broadband customer will be assessed a monthly charge on their statement. Broadband service is billed one month in advance. Install fees & 1st month of service is required before installation of service. All above monthly prices are estimated (All prices subject to change). Broadband speeds may vary by location.Customer Signature Date Month Day Year CAPTCHA
