Professional Documents
Culture Documents
Service Application Form
Service Application Form
Service Application Form
I nc electronic ñ\atcrricnt of xccD:unt ano otncr notices via email and S MS enall apply th ñ same Iago! effects, validity ano ñfforccaDility.
Prl mary E malI A ddrc ss' 1. Prlm a ry Mob IIe No.: — —
Secondary E-mall Acldress: 2. Secondary Moblle No.: — —
+ For any ‹zhangr° -.n run lnlormallnn mrnllnnñn ahme, kinn y v bit its a\ https:/.'arr:ment tJpr1a!n rnri'/°rg°.ill.rom ’
RESIDENTIAL
> Home Ownership: M Owned El Livlng with Relatives M Mortgaged M Rented Company—paid M No MYes ‹Please attach Guarantee Letter)
> Years of Resloency: 3 months Name of Lessor/owner: Ariel Senabuen Contact No/s.: N/A
> House/Room No. /FIc›cir: BLK. 11 LOT 17 ApartmenVCompound/Building, Street: KALAW STREET
> Subdlvlslon: PUROK 12, UNIT 5 Barangay. COMMONWEALTH Munlclpally/City: QUEZON CITY
Province: Zip code: 1121
COMMERCIAL
Room No. /FIoor Compound/Buiiding: Street:
Subdiv1sion: Barangay: Mut›lclpality/City:
Province: Zip code:
I_j FIBERX 1500 Php 1.500 Php 125/24mo. a IBIZ PLAN 10 Php 4,000 Php 2OB/24mc | O MICROBIZ 1OD0 Php 2,000 Php 125/24mo
O FIBERX 2500 Php 2,500 Php 125/24mO O IBIZ PLAN 20 Php 6,000 Php 125/2‹*o. | O MlCROBiZ 3o00 Php 3,000 Pip 125/z4nio
O FIBERX 3500 Pip 3,500 Php 125/12mo.
a IBIZ PLAN 30 Php 9,000 Php 83/Demo. 'with • *a^‹ ^ayme optlon a‘ Phe 2.soo
If FIBER Xtreme 4500 Php 4,500 WAIVED
a IBIZ PLAN 40 Pip 12,000 Php 83/24mo. i. Hicro6iz palate is not recamended for internet
O FIBER Xtreme 7000 Php 7,000 WAIVED cafe.
a IBIZ PLAN 50 Php 15,000 WAIVED 2. Ideal for not more thap S users / commuters.
^ •« prl es are VAT iiJcIouix’e.
f4ANDATORY REQUIREMENTS
RESIDENTIAL COMMERCIAL
D Government-issued ID O Government Issued ID O Government Issued JD of Representative
Id Proof of biiling l›
notHia1es Single Proprietor Partnership/Corporation Foreign Embassy
n Proof of income iz •au• i•u Ld Business or Nayors Permit z SEC Registration and Business/Nayor‘s Ld Authorized Letter I am Ambassador
+ Permit T BID/COIL c BIR/COR m Proof of Identification horn Auth0rlzed
¿ Corporate Secretary’s Certificate ra squared› Signatory
If renteo
O Lease contras t or
Endorsement from lessor
Where did you learn abaut our offe« g Billboard / Ej Leaflets ,’ Radio / LJ TV EJ Internet / Cj Friend Referrals / Others
This portion is to be filled-out by custornei service representative.
Account No.: for Internet: - O.R No.
Special Instruction- Salesman code: INH-002-009
unDeRTAKlNG
I hereby subscribe to tho Internet Sender orConverge ICT So/uxons, /NC., subject to my payment o/ Installation & Ee»lpment
Fee and Subscription Deposit wfilch nre nor›-'•.Funda6/e in tfie e.vent thnt my subscAptlon. Is pre.•te.rmlnal‹• prior to the
completion ofrhe ag/•eed yrescr/ded teas acer /.n/ca/ nsta//ation. / agree teat my subscription hereln Is Intended based on
my sr 6scrijorion tem1s ancf condi/Jorts as slips /arecf ml rue atrac/1ed TERMS AND C6AD/WONS form. / lust-her agree MICAH G. DEJUMO
thai' a.'I equipment installed in my designated address snail not se rransFerred to any otner locauon aha shall remain roe
property of Converge and In the eveni ofc//sconnecr/on will be no/cintar/\ sr/rrenaerea to Conve+ge wlllnout tne need of
any dern.and. App#canCsSl#npCureoverPrfn›edName