| Physical
Address of Service: |
City: |
| State:
Colorado |
| Billing
Address: |
City: |
| State: |
| ZipCode: |
| Email
Address: |
| Contact
Telephone: |
| What
number would you prefer to have DSL on? |
DSL
number: |
| VailNet/ColoradoNet
recommends having DSL ride over your fax number, if you have a fax number? |
| **Do
you have a phone system, alarm system, or long distance blocking system? |
Yes: |
| No: |
| What
speed would you prefer to have? * Please circle your
choice! Speeds may vary due to phone line quality! |
|
256/256k
|
Up
to 1.5Megs
|
| Do
you wish to RENT the DSL modem for $5.00 per month or PURCHASE the DSL
modem for $59.95? Please circle your choice. |
RENT
|
|
PURCHASE
|
**
Note: Phone systems, alarm systems and long distance call blocking system
"block" the DSL signal preventing it from working. Special wiring
may be required if you place DSL on a phone number that runs through a phone
system or alarm system, which would require paying a third party to do such
work. If you have any questions regarding which line should be used for
DSL please call VailNet/ColoradoNet.
Your
signature below constitutes your authorization for VailNet/ColoradoNet to
place a firm order with the telephone company for the provisioning of telephone
work necessary to provide you with VailNet/ColoradoNet DSL service for a
minimum period of one year. You understand that the telephone company will
bill you an installation charge for adding DSL to your telephone line, will
bill you monthly service charge for having DSL on that line and will bill
you a monthly charge for rental of the DSL modem/router required for use
of DSL service. Any disputes regarding these charges are between you and
the telephone company. You also understand that VailNet/ColoradoNet will
bill you for your Internet connectivity through the DSL modem and that we
will provide you with technical support and a mailbox on our system.
If
you terminate service prior to using it, the telephone company may charge
you a percentage of their startup fee. Once service is activated, termination
of service prior to the end of your annual commitment may result in early
termination charges from the telephone company as well as from VailNet/ColoradoNet.
Your signature further acknowledges your understanding and agreement to
enter into a one-year term agreement for service. You also understand that
failure to return a rented modem to the telephone company after discontinuing
service will result in the telephone company charging you. The individual
who signs this document represents that they are authorized to make changes
to their phone lines and that they are authorized to enter into this agreement.
Credit
Card Number:____________________________ Exp:____________
Customer
Signature: _____________________________ Date: ___________
VailNet/ColoradoNet
Box 2812, Avon, CO. 81620 970-949-3318 voice 970-949-3380 fax