Double Play Fiber Application Click Here to Download Application 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 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 Additional Contact(s)NameCell # Add RemoveLogin Name Preferred Email Address Plan Options $176.00 Double Play-Expanded Fiber TV-30 Mbps Broadband $186.00 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 $18.99 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 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 Static IP Address $10.00 per month (The following items require a Static IP: Security Cameras & VPN’s) Customer has own wireless router, customer will program (No Charge) *Router purchased from Sirentel, comes with a 1year 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’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
