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Name ______________________________  Phone Number _____________________

Address ____________________________  Email Address ______________________

             ____________________________   DSL Customer  y/n __________________

Daytime Phone Number __________________________

Local Package ______   Basic Package ______   Expanded Basic Package ______

HD Copper ________  HD Optic _________  DVR Set Top Box __________

HDTV Information - HDMI Connection   Yes / No             DPI is  1080  or  720

Movie Package(s) _______________________________________________________

Installation     $50.00                  Deposit     $30.00____

Set Top Box (2 Amino) Included in installation price

        Type of TV wiring (coax, CAT5)   ______________________________________  

        Number of Television Sets  __  _________________________________________

The number of TV sets capable of being connected for our video service may be limited depending on the distance from the switch and the quality of wiring and equipment in your home.

ALL HOUSE WIRING IS THE RESPONSIBILITY OF THE CUSTOMER AND MUST BE COMPLETED PRIOR TO HOOK-UP OR THERE MAY BE ADDITIONAL CHARGES.  YOU MUST PAY FOR LOCAL PHONE SERVICE TO HAVE VIDEO. 

I take full responsibility for insurance coverage on all equipment including the Set Top Boxes.  The Set Top Boxes will be returned to Glandorf Telephone Co. , Inc. in good shape if/when service is disconnected. I am responsible for having/using acceptable care at all times. I understand there could be extra charges for labor and material if necessary.

      Appointment Date __________________________        Time ____________________

 Signature _________________________________        Date _____________________

 Comments ______________________________________________________________

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