DELCOM SERVICE REQUEST FORM

INTERNET ACCESS SERVICE REQUEST

Thank you for choosing Delcom Broadband
1. CUSTOMER INFORMATION
Full Name

First NameLast Name
Today's Date

MonthDayYear
Date
Driver's License No. & State
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
2. ADDRESS INFORMATION
Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. AUTHORIZED CONTACTS
The individuals listed below are authorized to receive account information and to make change to the account.
Full Name
Title / Relation
Phone Number
Format: (000) 000-0000.
Full Name
Title / Relation
Phone Number
Format: (000) 000-0000.
Full Name
Title / Relation
Phone Number
Format: (000) 000-0000.
4. INTERNET PLAN SELECTION
Please select one
Monthly Recurring Charge (MRC) *Data rates not guaranteed.
Additional Fees
- A $5.00 per month administrative and equipment lease fee applies.
- A $50.00 installation fee is due at the time of application
5. BILLING PREFERENCE
6. TERMS & CONDITIONS
- Delcom will conduct a site survey to access signal strength for service. A Delcom representative will contact the Customer to schedule installation.
- Customer will permit Delcom to place equipment on the customer's property. The Customer will leave equipment to be retrieved when service is discontinued. If Delcom equipment is missing and/or damaged, the Customer agrees to pay $150 for the equipment Additional information concerning this service is available at delltelco.com
- The Customer is at least 18 years of age and agrees to pay for the service selected
- I agree to the following terms: The Monthly Recurring Charge (MRC) cost of a Subscriber Module & Wireless Router provided by Delcom. Delcom retains ownership of the Subscriber Module & Wireless Router which must be returned upon discontinuance of service.
7. AUTHORIZATION
Authorized Customer Signature
Date

MonthDayYear
Date
Print Customer Name
PECOS OFFICE
1208 Meadowbrook Dr, Pecos, TX 79772
www.delltelco.com
EQUIPMENT NOTICE
Equipment includes a Subscriber Module
& Wireless Router.
SUPPORT POLICY
The first 30 days of troubleshooting are provided at
no cost. After 30 days, support is billed $80 per hour.
Should be Empty:

INTERNET ACCESS SERVICE REQUEST

1. CUSTOMER INFORMATION

2. ADDRESS INFORMATION

3. AUTHORIZED CONTACTS

4. INTERNET PLAN SELECTION

6. TERMS & CONDITIONS

7. AUTHORIZATION