Service Order Form

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

Tax Exempt
We will need a copy of the Exemption Certificate.

	Billing Address		Physical Address (if different)
Address		Address
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

Option 1

Local Phone Service, Unlimited Long Distance*, Premier Digital Cable Service**, and Standard Internet ($110.00)

Option 2

Local Phone Service, Unlimited Long Distance*, Lifeline Basic Cable Service***, and Economy Internet ($80.00)

Option 3

Local Phone Service, Unlimited Long Distance*, Lifeline Basic Cable Service***, and Standard Internet ($89.99)

Pro Unlimited Package

Includes: Unlimited Local & Long Distance (Continental US); International & 900 blocking; Three Way Calling, Caller ID & Call Waiting ($42.11)

Pro Economy Package

Includes: Unlimited Local Calling; International, 900 & Long Distance Blocking; & Caller ID ($21.59)

Add Wireless Router $5.95

Add a wireless router to any package. ($5.95)

*	Unlimited Long Distance-Continental US Only
**	230 Digital Channels for one room & 26 Lifeline Basic Channels in additional rooms with Digital TVs. Upgrade additional rooms from 41 Lifeline Basic Channels to 230 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 47 Lifeline Basic Channels. Upgrade Analog TVs from 26 Basic Channels to 41 Channels @ $5.00/Month/Room.
*******	26 Lifeline Basic Channels on all Digital TVs. Analog TVs with out a Digital Receiver will only receive 26 of the Lifeline Basic Channels. Upgrade Analog TVs from 26 Basic Channels to 41 Channels @ $5.00/Month/Room. Lifeline HD Channels require an HDTV.

Individual Services (If No Package Selected)

Cable	Lifeline Basic Cable TV (56 Channels) $29.99 Premier Digital Cable TV (180 Channels) $62.50 Super Saver Cable TV (192 Channels) $75.00 Gold Cable TV (222 Channels) $97.50

Internet	Economy $20.99 Standard $39.99 Express $55.99 Advanced $79.99 Wireless Router $5.95

Phone Service	Local Telephone Service with Three Free Calling Features (Not available in all areas) $18.51 Long Distance Telephone Service .059 cents/min

Activation/Installation Charges Applicable As Outlined Below

Package Plans

Month to Month Package Plan: $150.00

1 Year Term Package Plan: $75.00

2 Year Term Package Plan: $0.00. All activation/installation charges are waived.

No Package. $50 per service selected.

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”.