|
* First Name |
|
|
MI |
|
|
* Last Name |
|
|
* Social Security No |
(numbers only, no dashes) |
|
Service Address |
|
* Building |
|
|
Apartment |
(if applicable) |
|
* Lease status |
Tenant Subtenant |
|
Lease Start |
(format MM/DD/YY) |
|
Lease End |
(format MM/DD/YY) |
|
Billing Address (if different) |
|
Billing Address 1 |
|
|
Billing Address 2 |
|
|
Billing City |
|
|
Billing State |
|
|
Billing Zip |
|
|
Contact details |
|
* Email |
|
|
Cell Number |
(numbers only, no dashes etc) |
|
Permanent phone # |
(numbers only, no dashes etc) |
|
Services Ordered |
|
Budget Telephone |
at $12.95 per month, $29.95 installation |
|
Unlimited Telephone |
at $39.95 per month, $29.95 installation |
|
Standard 10 Mbit Internet |
at $39.99 per month, $29.95 installation |
|
Xtreme 20 to 100 Mbit Internet (Speed based on location) |
at $59.99 per month, $29.95 installation |
|
Dish Network Receivers |
|
|
Programming packages |
|
|
|
(List programming packages required. We will contact you to confirm programming packages and choice before installation) |
|
Packages and package add-ons |
|
The Works digital |
$39.99 per month, free installation |
|
The Works Xtreme Digital |
$59.99 per month, free installation |
|
The Works Buddy add-on |
$13.95 per month, free installation |
|
The Works Xtreme Buddy |
$18.95 per month, free installation |
|
Final Order details |
|
* Date service requested |
(format MM/DD/YY) |
|
Special instructions |
|
|
* Confirmation |
By clicking the ‘Submit’ button below I confirm that I have read and agree to comply with Phillynet’s Terms and Conditions and Acceptable Use Policy set out here. |