Double Play Fiber 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 NumberService 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 Additional Applicant NameNameAdditiional Applicant Cell # Add RemoveLogin Name Preferred Email Address Plan Options $191.00 Double Play-Expanded Fiber TV-30 Mbps Broadband $201.00 Double Play-Expanded Fiber TV-50 Mbps Broadband Total # of TVs to be connected at install Additional Set top Box(s) $4.95 per monthDVR $11.95 per month*Additional Wiring Fee for Set top Box(s) $20.00 per locationOther Options - Contact Office for More Informatiton HBO $15.99 Showtime $17.95 Cinemax $15.99 Starz/Encore $15.99 HD Basic Equipment fee $2.99 HD Tier $9.99 Variety Tier $9.99 Router Information 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, comes with a 1year limited warranty. All prices subject to change.Untitled Static IP Address $10.00 per month (The following items 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’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 Double Play service Set Top Box(s) must be returned to the Siren Telephone’s business office or a $172.95 charge will be assessed. Fiber Modem stays at the residence. Double Play customers will be assessed a monthly charge on their statement. Double Play service is billed one month in advance. Install fees & 1st month of service is required before installation of service. All above plan prices are estimated all prices subject to change.Customer Signature Date Month Day Year CAPTCHA
