BIDA FIBER PLAN APPLICATION FORM

First Name:

Middle Name:

Last Name:

Date of Birth:

Civil Status:

Mothers Full Maiden Name:

Primary Mobile Number:

Secondary Mobile Number:

Email Address:
Alternate Email Address:

House Address:
OWNED ____ RENTED____
Landmark:

Longitude and Latitude:

Household Income:

_____Employed ______ Self-employed

Position:
Company Name:
Company Address:

Plan : BIDA FIBER (35MBPS)

-3 years Contract
-up to 6 gadgets only
-no LAN port available
-unlimited internet

INSTALLATION FEE:

CASH_____(1,500) INSTALLMENT_____(100 pesos for 18 months)

Breakdown: Breakdown:
1,500(cash payment of installation fee) 888 (one month DEPOSIT- to be used at the last month
888 (one month advance) of contract)
TOTAL=2,388.00 TOTAL=888.00

_________________________ Date:___________________
Customer Name and Signature
Date:

Sir/Ma’am,

This is to authorize ,a

resident of , to use my

as a proof of billing for their

BIDA FIBER Internet Application purposes only.

Thank you.

_________________________________ Date:___________________
Owners Printed Name and Signature