Fiber Broadband Application

DOB
Federal Employer Identification Number

Service Address

Mailing Address

Broadband Speeds
(estimated prices, taxes & fees may vary)
$99 Installation Fee
Wireless Router Option
*Router purchased from Sirentel has 1 year limited warranty.
(Must be 8 letters, no more than 12)
(or we will default to My Network)
(To secure your router settings)

I, the undersigned, am requesting that Siren Telephone Company plow fiber optic to my premise. By signing the agreement, I agree to the digging that is required for service from Siren Telephone Company.
Date