Business Customer Information and Service Application Form

Please Write in CAPITAL LETTERS

1. Company/Business Name

2. Business and Billing Address Details

TYPE OF BUSINESS: MICROBUSINESS/SOLE PROP PARTNERSHIP COOPERATIVE GOVERNMENT CORPORATE
UNIT/ FLOOR/ BUILDING NAME/ STREET NO./ STREET NAME

BARANGAY/ MUNICIPALITY/ TOWN

CITY/ PROVINCE COMPANY/PERSONAL TIN

LANDLINE NUMBER FINANCE OFFICER

MOBILE NUMBER FINANCE OFFICER EMAIL ADDRESS & CONTACT NO..

EMAIL ADDRESS SEC REGISTRATION NO.

Website

3. Authorized Signatories and Billing Recipient

A. NAME: (LAST NAME, FIRST NAME, MI)

TITLE/POSITION LANDLINE NUMBER

EMAIL ADDRESS MOBILE NUMBER

B. NAME: (LAST NAME, FIRST NAME, MI)

TITLE/POSITION LANDLINE NUMBER

EMAIL ADDRESS MOBILE NUMBER

BILLING RECIPIENT: (LAST NAME, FIRST NAME, MI)

TITLE/POSITION LANDLINE NUMBER

EMAIL ADDRESS MOBILE NUMBER

4. Delivery Details
*For multiple sites, please attach summary of address/es with corresponding two (2) company representatives and contact information. (THIS MUST BE FILLED OUT)
Delivery Details is the same as the Billing Address
UNIT/ FLOOR/ BUILDING NAME/ STREET NO./ STREET NAME

BARANGAY/ MUNICIPALITY/ TOWN

CITY/ PROVINCE ZIP CODE

RECEPIENT NAME A RECEPIENT NAME B

EMAIL EMAIL

CONTACT NUMBER CONTACT NUMBER

5. Installation Address (For Broadband Products Only)

UNIT/ FLOOR/ BUILDING NAME/ STREET NO./ STREET NAME

BARANGAY/ MUNICIPALITY/ TOWN

CITY/ PROVINCE ZIP CODE

6. Optional Billing Instructions

Enrollment to Online Billing
Administrator's name:
Contact Number and Email Address:

E-SOA (automatically waives the Hard Copy SOA and receive SOA via email)
Email Address:

CUSTOMER CONFIRMATION
I affirm the above given information is true and correct and hereby authorize SMART Communications, Inc. to verify such information from whatsoever sources it may consider appropriate.
I understand that I may be requested to submit additional requirements to facilitate the processing of this application

I have read and accepted the (1) SMART BUSINESS SOLUTIONS Terms and Conditions; and (2) SMART BRO ENTERPRISE EDITION Terms and Conditions.
I am fully aware that I will only be able to use the services where SMART Communications Inc. has coverage. It is fully explained to me and I fully understand that the upload and download speed
may vary depending on network availability and location. I am also aware that my broadband service, can be used only with SMART Broadband-provided equipment and/or peripherals. Standard call, text and data charges
would be followed.

BUMATAY ANJONIEL / P08126

Authorized Signatory Sales Associate
Signature over printed name Signature over printed name
MARIVYN CASAÑARES
Date: Sales Supervisor
Signature over printed name
EUAN REX TORALBALLA
Area Sales Head/Business Head
Signature over printed name
(Version 9.0)
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