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RESIDENTIAL WIRELESS BROADBAND APPLICATION FORM

This form is for Fort Chipweyan / First Nations / Métis Settlement Residents ONLY.

PERSONAL INFO:

Full Name:	Company (if applicable):
Address:	City:
Postal Code:	Work Phone:
Home Phone:	Cell Phone:

RESERVE INFO: (for First Nation residents ONLY)

Reserve Name:	Reserve Community:
Treaty # / Exemption: (Required or GST will be charged)

SUBSCRIPTION PLAN:

I 100 (Residential)
Installation Fee: $250.00*
$59.00/month+GST
Up to 1.0 Mbps for download
Up to 700 Kbps for uploads
3 email accounts (10 MB) each
10 GB/month downloading
2 GB/month uploading
Non-Static IP address

*50% payment ($125.00) of the Installation Fee is required to secure and arrange an installation date with SIS SYSTEMS and remainder payable at time of installation.

ADDITIONAL HARDWARE REQUEST/OPTIONS:

Please check off the boxes for additional hardware and or software and your SIS SYSTEMS Technician will install and configure the following you have chosen upon installation.

		Network Router / Firewall ( HIGHLY RECOMMENDED ) -- $109.00* Protects your computer, data, resources and network from internet attack and unwanted traffic which will harm and slow down your computer and network.
		Antivirus Software with One Year Subscription -- $59.00* Works in protecting and blocking your computer from viruses via email, Internet browsing and general use which harm and slow down your computer and network.
		Antispyware Software with One Year Subscription -- $49.00* Protects your computer and network from harmful spyware programs which slow down your computer and internet.

AUTHORIZATION:

I hereby authorize and request the installation of High Speed Internet Service at the above address. I understand and agree to the following:

I have read, understand and agree to the High Speed Internet terms of service contained as part of this form.
I agree to pay the monthly fee for this service as listed on this form. If I fail to pay this fee my High Speed Internet service will be disabled until payment is received.
A subscriber unit will be provided by the installer. The provided subscriber unit is owned by SIS Systems. If you cancel your internet service SIS SYSTEMS will remove the subscriber unit.
I will be contacted by SIS Systems to arrange installation.