Copper Broadband Application

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Applicant Name

Applicant Cell #

Driver's License (ID#)

State

DOB

FEIN #

Federal Employer Identification Number

Contact Name

Contact Cell #

Service Address

Street Address City State ZIP Code

Township

Mailing Address

Street Address City State ZIP Code

Preferred Email Address

Broadband Speeds:

2 Mbps $53.00 per month (estimated, taxes & fees may vary)
$99.00 Installation Fee

Wireless 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) One time Fee $176.00

Wireless router not purchased from Sirentel $32.00 programming fee

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)

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

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