Service Change Form

This is for Red Bolt Broadband ONLY. Any changes to your electric account need to be made separately. By submitting this form I am requesting a service change, for my Red Bolt Broadband service provided by Continental Divide Electric Cooperative, Inc.

Customer Name *

Account Number

Service Address *

Phone *

Email Address *

example@example.com

By changing my service plan, changes and charges as shown on the current customer agreement will reflect the next billing cycle.

Account Change *If adding or cancelling IP address please choose upgrade or downgrade option. *

Upgrade Downgrade Add Device Return Device

If you would like to change your service package or add a device, please choose from the following options. *

$49.95/month: 100/100 Mbps $59.95/month: 300/300 Mbps $89.95/month: 1000/1000 Mbps (1 Gig) $7.00/month: Wireless Router Rental $3.95/month: 5Ghz WiFi Extender $3.95/month: Public IP address

By adding or returning equipment, charges as shown on the current customer agreement will reflect on my bill, from the date on this form going forward.

Router / 5GHz Wi-Fi Extender

Pick-Up Return

Router / 5GHz Wi-Fi Extender Pick-Up FSAN:

Router / 5GHz Wi-Fi Extender Return FSAN:

Reason for Return/Exchange

*I understand that, if the equipment needs to be cleaned there will be a $20 cleaning fee, per device, assessed.

If the equipment is returned unusable, I am responsible for full retail charges of equipment. i.e.- Returned without power cord or damaged.

$20.00 Cleaning fee required?

Yes No

Signature *

Clear

Date

200 East High Street / PO Box 1087 / Grants, New Mexico 87020 / redboltbroadband.com / Ph: 505.658.2487 / Fx: 505.287.2234