Copper Broadband Application Click Here to Download Application Siren Telephone Company: Applicant Name Applicant Cell #Driver's License (ID#) StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDOB Month Day Year FEIN # Federal Employer Identification NumberAdditional Applicant Name Additional Applicant Cell #Service Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Township Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Login Name Preferred Email Address Broadband Speeds:2 Mbps $56.00 per month (estimated, taxes & fees may vary)$99.00 Installation FeeWireless Router Option D-Link Dual Band Eagle Pro AI Router onetime fee $87.50 Adtran 834-5 Dual Band Wireless Router onetime fee $191.00 Wireless router not purchased from Sirentel $32.00 programming fee Advanced Wireless Router w/app Based Setting, will require additional programming fee depending on model (call for more details). Customer Has Own Wireless Router, Customer Will Program (No Charge) *Router purchased from Sirentel has 1 year limited warranty. All prices subject to change. Static IP Address $10.00 per month (The following items may require a Static IP: Security Cameras & VPN’s) 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)I, the undersigned, am requesting a Siren Telephone Company’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 diagnosis, repair and/or replacement of the modem. Upon termination of Broadband service, the modem must be returned to the Siren Telephone Company’s business office or a $150.00 charge will be assessed. A $99.00 charge for early termination plus number of months left of 6-month connection will be accessed. Broadband customer will be assessed a monthly charge on their statement. Broadband service is billed one month in advance. Install fees & first month of service is required before installation of service. Installation Fee $99.00 All above monthly prices are estimated (All prices subject to change). Broadband speeds may vary by location.Customer Signature Date Month Day Year CAPTCHA