Rainbow broadband

CUSTOMER CONTACT INFORMATION

CUSTOMER BILLING INFORMATION

Customer:

Contact Person: 

Address:

Address:

City / State / Zip:

City / State / Zip:

Phone:

Phone:

E-mail:

E-mail:

RAINBOW BROADBAND, INC. — REPRESENTATIVE

Name:                                                                 Telephone:

E-mail:                                                                Facsimile:

SERVICE LOCATION INFORMATION

Location 1

Address:

Floor / Suite:  

City, State, Zip:   

Phone:  

Contact:  

Location 2

Address: ........................................................................

Floor / Suite: ................................................................

City, State, Zip: ..........................................................

Phone: ...........................................................................

Contact: .........................................................................

SERVICE OVERVIEW:  INCLUDING NON-RECURRING INSTALLATION CHARGES AND MONTHLY RECURRING SERVICE CHARGES

Service Type:

Circuit Speed:

Term:

Ethernet

   Internet Access

   Point-to-Point

Other:

Hardware:

Total Install Cost (NRC):

Total Monthly Recurring Cost (MRC):

CREDIT CARD INFORMATION

Credit Card Number:

Expiration Date:

Card Type (AMEX, Visa, MasterCard):

Card Holder Name: