Expanded Fiber TV Application

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DOB
Federal Employer Identification Number
Service Address
Mailing Address
Additional Contact Name
Name
Additional Applicant Cell #
 

Monthly Service Charges
*Estimated plan prices, taxes & fees may vary
*There is a monthly modem maintenance fee of $4.75, which covers the diagnosis, repair and/or replacement of the modem.
Type of TV Connection to Television
*$125.00 installation fee, Plus First Month of Service Charges.
Note: Each location for TV’s, must have CAT5 wired from fiber modem to location. Drilling may be required.
Other Prices:
Additional Wiring Fee Per Location $20.00 x_________ (Total STB’s)
Reconnect Non-Pay $32.00
Vacation Rate Reconnect $10.00
Remote Control Replacement $15.00
Set Top Box / Remote Not Returned $172.95

**PRICES & PROGRAMMING FEES SUBJECT TO CHANGE

SIREN TELEPHONE COMPANY HAS A 6 MONTH MINIMUM CONNECTION FOR SERVICE

Date