Triple Play Fiber Application

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

Local Telephone + Long Distance + Broadband + Expanded Fiber TV W/ HD Basic Included
(estimated plan prices, taxes & fees may vary)
*All plans above come with Free Extended Community calling if with Sirentel long distance
*$125.00 Installation Fee

TV Options & Information:

$4.95 per month
$11.95 per month
*Additional Wiring Fee for Set top Box(s) $20.00 per location
Other Options
Included with each plan

Router Information
*Router purchased from Sirentel, comes with a 1year limited warranty. All prices subject to change.
Untitled
(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 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. All prices subject to change.

There is a monthly modem maintenance fee of $4.95, which covers the diagnosis, repair and/or replacement of the modem.

Upon termination of IPTV service, the Set top Box(s) must be returned to the Siren Telephone’s business office or a $172.95 per box charge will be assessed.

Triple Play customers will be assessed a monthly charge on their statement. Triple Play service is billed one month in advance. Install fee, first month of service and router fees due before install.
Date