Residential Activation & Installation Form Viewing this Form is a confirmation that Internet has been activated and you have connectivity the Internet VIA VeroLAN broadband Service. Please take a moment and fill out as much as you can of this form to help us insure a proper setup of your new account. (Fields with * are required) Section (1) - Contact Information * First & Last Name: * eMail: * Installation Address: * City, State & Zip code: * Home Phone: Work Phone: Ext. Mobile: Section (2) - Billing Information * Service Start Date: --Day-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 --Month Year-- January 2005 February 2005 March 2005 April 2005 May 2005 June 2005 July 2005 August 2005 September 2005 October 2005 November 2005 December 2005 * Recurring Monthly $: --Select One-- Residential Advantage - 1024/192Kbps - $99.99 Residential Premium - 768/192Kbps - $89.99 Residential Plus - 512/128Kbps - $79.99 Residential Basic - 384/128Kbps - $69.99 Residential Lite - 256/64Kbps - $59.99 ---------------------------------- Other - See Notes * Prorated 1st Month $: = (service plan/30) x number of days left * Monthly Billing Method: --Select One-- Credit Card Auto Pay Send Bill by email Please note that a printable invoice will be emailed monthly regardless of billing method selected above. Credit Card: cvv: Exp: Name on Card: Card Zip Code: Billing Notes: Section (3) - Equipment and System Configuration * Invoice Number: * Installed By: --Select One-- Khalil Daoudi Roberto Rangel Jon Sell Self Installed --Select One-- Khalil Daoudi Roberto Rangel Jon Sell Self Installed * Antenna: --Select One-- 13 DBi Pannel 15 DBi Pannel 19DBi Pannel 18 DBi Grid Dish 21 DBi Grid Dish 24 DBi Grid Dish 8 DBi Window Antenna 5 DBi Indoor Mini Omni Other see notes * SNR: DBi * Visible Access Point: --Select One-- YES NO * Willing Repeater AP: --Select One-- YES NO * Cable Run: /Feet * Wall Plate: --Select One-- YES NO * Wireless Bridge: --Select One-- Ethernet Converter II - Outdoor Proxim ORiNOCO AP2000 - Repeater/Relay Linksys WET54G - Outdoor Linksys WET11 - Outdoor Smart Bridge 2110 - Outdoor Other - See Notes * Router Installed: --Select One-- EE400-R GigaFast BEFSX41 Linksys SMC7004VBR Baricade Other _ List Below * Bridge/Router Assigned IPs: General Notes:
Residential Activation & Installation Form Viewing this Form is a confirmation that Internet has been activated and you have connectivity the Internet VIA VeroLAN broadband Service. Please take a moment and fill out as much as you can of this form to help us insure a proper setup of your new account. (Fields with * are required)
Section (1) - Contact Information
* eMail:
* Home Phone:
Section (2) - Billing Information
* Recurring Monthly $:
* Prorated 1st Month $:
* Monthly Billing Method:
Please note that a printable invoice will be emailed monthly regardless of billing method selected above.
Section (3) - Equipment and System Configuration
For more details please call us at 703-266-1000