Carolina - Account Creation Information Form

CAROLINA SMART HOME ACCOUNT CREATION SYSTEM

Office will contact you immidiately once the account has been processed through the system. Be sure to complete all requirements to avoid delays.

You can also text our support team at

803-621-3022

Sales Rep's Name*

Sales Rep's Cell Phone #*

Customer's Name*

First NameLast Name

IMPORTANT

If you are adding google devices, customer MUST have a gmail email address and must be present at time of install to link google and adt apps.

Customer's Email*

example@example.com

Customer's cell phone #*

Last 4 of customer's social*

D.O.B info*

Premises address (include city, state, and zip code)*

County*

Previous home address

Name of Emergency Contact Person

Relationship to customer

Emergency Contact Phone Number

Verbal Pass Word To Cancel Alarm With Central Station (up to 10 letter word)

Up to 10 letters

Account Credit Type*

ADT ResidentialADT CommercialADT In-House Program

Please make sure that you verify the billing information to avoid delays or declines. Collecting ACH info is required to schedule a deal.

ADT payment Type*

Checking AcctSavings AcctCredit or Debit Card (Confirm expiration date is not within 6 months)ADT - Manual Invoice (750 credit score and up ONLY), There is a 2X deduction

For ACH - Bank Name - MANDATORY IF ACH

For ACH - Need Acct-info #

For ACH - Need Routing-info #

For Debit/CC, provide first 8 digits #

For Debit/CC, provide last 8 digits #

Card exp-date (month and year), Example: May 2028

Are you including Google Nest Aware Plus ($6.00 rate add-on)?*

Monthly Monitoring Rate (Including Nest Aware Plus if is included in the service package)*

Google Nest Aware Plus (10 day continous recording) only applies for Google indoor, outdoor, and hardwired doorbell cameras only. If you are only doing a google wireless doorbell camera and no other video device, you cannot use the Nest Aware Plus package, it has to be the standard package.

Type Of Install (Company does NOT get involved in cancellations of previous alarm company)*

ADT - New Install (nothing in the home/business)ADT - Being Monitored - NOT Taking Over DeviceADT - Not Being Monitored - Not taking Over DevicesADT - Being Monitored - Taking Over DevicesADT - In-House Deal

Name of alarm company if system is being monitored (type "NA" if not being monitored)*

TYPE "NA" IF NOT BEING MONITORED OR NOT ONE IN THE HOME

Activation/Installation upfront fees we are to collect from customer*

Provide amount to be collected (not including monitoring)

Equipment upfront fees we are to collect from customer*

Provide amount to be collected (not including monitoring)

Contacts

Motions

Glass breaks

Smokes

Google outdoor cameras

Google indoor cameras

Google doorbells

Yale smart lock (provide color in the notes)

NOTES: All systems will come with 5" panel and radio. Please type N/A below if no other equipment is requested, otherwise, list all other equipment with quantities. Thank you*

Does customer have adequate Wi-Fi speed per camera/doorbell (2MB)*

Yes, I confirmed speed is adequateNo, I did not confirmedIt is border lineCustomer does not have Wi-Fi

EXISTING EQUIPMENT TAKEN OVER (warranty not provided)

INSTALL NOTES*

Best days customer is available for install (You can pick multiple days)*

Best times customer is available for install*

I hereby request to have my customer's credit pulled for approval and installation purposes. I affirm that I have been authorized by my customer to pull their credit in connection with this application. I agree that the information given is true, accurate and complete as of the date of this application submission. Please be aware that office may select to complete a verbal confirmation call with your customer. If customer fails the pre-install survey, deal will be removed from the board until issue is addressed.*

ACKNOWLEDGED

Rep's Signature*

COMPANY EMAIL