Wireless Signup Form If you are a human and are seeing this field, please leave it blank. Last Name First Name Email Address 1 Phone Alternate Phone City Billing Name (if different) Billing Address (if different) Billing City, State, Zip (if different) I accept installation and service agreement Please Select One Yes No Payment Method Please Select One Debit/Credit Card Automatic Payment Will Pay Online Invoice Method US Mail Hard Copy (additional charge) Email Invoice Monthly Service Charge Please Select One AC2 - $69/Mo AC4 - $79/Mo AC10 - $99/Mo I Understand the Installation Charge Please Select One Yes No I have read the service agreement Please Select One Yes No Checking this box acknowledges signing this document I am 18 Years of age or 0lder I agree to allow access to my property and roof Please Select One Yes No Comments Person Completing This Form
