Service Order Form
Businesses: Please call our Sales Department for quotes on
Telephone and Internet Services. 888-713-0217

This form should only be filled out by Property Owners. All services are subject to the Terms And Conditions.

Customer Information
Customer Name (Exact Legal Name)
 
Location Type

We will need a copy of the Exemption Certificate.
Billing Address Physical Address (if different)
Address   Address
City   City
State   Zip   State  Zip
Contact Name
 
Contact Telephone No.
 
Email Address
 
Fax No.
Federal ID        OR   Social Security No.
   
State Id No.
Lines

Please enter the main billing telephone number in the appropriate textbox. This is the main number of the location that additional lines if any will be billed to. If you need a second billing telephone number, please enter it in the provided textbox.

Main Billing Telephone #   Additional Billing Telephone #
Packages
Local Phone Service, Unlimited Long Distance*, Lifeline Basic Cable Service***, and Economy Internet ($111.99)
Local Phone Service, Unlimited Long Distance*, Lifeline Basic Cable Service***, and Standard Internet ($121.99)
Local Phone Service, Unlimited Long Distance*, Premier Digital Cable Service**, and Standard Internet ($142.00/month)
Local Phone Service, Unlimited Long Distance*, Premier Digital Cable Service**, 18 Starz and Encore channels, and Standard Internet ($154.00)
Local Phone Service, Unlimited Long Distance*, Premier Digital Cable Service**, 33 Starz, Encore, HBO, Showtime, and Cinemax channels, and Standard Internet ($177.00)
Local Phone Service, Unlimited Long Distance*, Premier Digital Cable service**, 33 Starz, Encore, HBO, Showtime and Cinemax channels, and Standard Internet (Add to nightly rental fee).
* Unlimited Long Distance-Continental US Only
** 180 Digital Channels for one room & 56 Lifeline Basic Channels in additional rooms with Digital TVs. Upgrade additional rooms from 56 Lifeline Basic Channels to 180 Digital Channels @ $5.00/Month/Room for Digital Service, or $10.00/Month/Room for HD/DVR Service (Lifeline HD Channels require an HDTV. National HD Channels require an HDTV & HD Receiver). Please note that Analog TVs with out a Digital Receiver will only receive 25 of the 56 Lifeline Basic Channels. Upgrade Analog TVs from 25 Basic Channels to 56 Channels @ $5.00/Month/Room.
*** 56 Lifeline Basic Channels on all Digital TVs. Analog TVs with out a Digital Receiver will only receive 25 of the 56 Lifeline Basic Channels. Upgrade Analog TVs from 25 Basic Channels to 56 Channels @ $5.00/Month/Room. Lifeline HD Channels require an HDTV.
Individual Services (If No Package Selected)
Cable



Internet




Phone Service

Activation/Installation Charges Applicable As Outlined Below
Package Plans



If Service is terminated pursuant to Sections 2.12.1 or 2.12.2 of the Company’s Terms And Conditions or if the Customer requests cancellation of Service after installation but prior to expiration of a minimum Service commitment period, Customer agrees to pay the Company the full amount of any waived installation charges, which shall be due and payable as of the effective date of cancellation or termination.


Individual Services: Installation/Activation Charge Per Service: $50.00
Purchase any individual service: Choose 1 service-installation/activation charge is $50.00; Choose two services-installation/activation charge is $100.00 (or $50/service).

Comments
By submitting I certify that I am at least eighteen years of age and that I have read and understand the terms and conditions of this letter of agency. I also certify that I am authorized to change or establish the services indicated above for this location. I am further authorizing Procom to do a credit check investigation and hold free from liability all creditors and other persons who may respond to “inquiries”.


 
SALES AGENT H100 Steve Liller