VeroLAN Support - Commercial BroadBand Activation Form

Commercial Broadband Service Initiation Form.
Viewing this Activation Form is a confirmation that Internet has been activated and you have connectivity the World Wide Web. Please take a moment and fill out as much as you can of this form to help us insure a proper setup of your new account. (Fields with * are required)

   Section (1) On-Site Person Contact Information

* Company Name:

* Installation Address:

* City, State & Zip code:

* First & Last Name:

* Title:

* Primary Phone:
Ext.

Alt. Phone:

* e-Mail:

Local Contact Notes:

   Section (2) Account Payable - Billing Information

* Billing Info.:

Billing Address:

City, State & Zip code:

First & Last Name:

Primary Phone:
Ext.

Alt. Phone:

e-Mail:

Billing Notes:

* Service Start Date:

* Recurring Monthly $:

* Prorated 1st Month $:

* Monthly Billing Method:

Credit Card: cvv: Exp:

Name on Card:    Card Zip Code:

Take $25 Off Activation when you select "Credit Card Auto Pay. Note: a printable invoice will be
emailed monthly regardless of billing method selected above.


   Section (3) Equipment, Install & System Configuration

Invoice Number:

Installed By:

Antenna: SN:

SNR Reading: DB Amplified:

Visible Access Point:

Cable Run: in Feet

Wall Plate:

Wireless Bridge: SN:

Router Installed: SN:

Assigned IPs:

General Notes: