Residential Activation & Installation Form

Viewing this Form is a confirmation that Internet has been activated and you have connectivity the Internet VIA VeroLAN broadband Service. 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) - Contact Information
* First & Last Name:

* eMail:
* Installation Address:
* City, State & Zip code:

*  Home Phone:

  
Work Phone:       Ext.
Mobile:

   Section (2) - Billing Information
* Service Start Date: 

* Recurring Monthly $:

* Prorated 1st Month $:

 = (service plan/30) x number of days left

* Monthly Billing Method:

Please note that a printable invoice will be emailed monthly
regardless of billing method selected above.
   
Credit Card:     cvv: Exp:
Name on Card:    Card Zip Code:
Billing Notes:

   Section (3) - Equipment and System Configuration
* Invoice Number:
* Installed By:
* Antenna:
* SNR: DBi
* Visible Access Point:
* Willing Repeater AP:
* Cable Run: /Feet
* Wall Plate: 
* Wireless Bridge:
* Router Installed: 
* Bridge/Router Assigned IPs:
General Notes:





        

For more details please call us at 703-266-1000