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Converge ICT Application Form

The document is an application form for internet service from Converge ICT. It requests personal and contact information from applicants, as well as residential and service details. Applicants must select an internet plan and installation fee payment terms. Requirements include proof of billing, valid ID, and a Google Maps screenshot pinpointing the service location. By submitting the form, applicants agree to terms of service and that equipment will remain Converge's property.

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renton locker
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591 views3 pages

Converge ICT Application Form

The document is an application form for internet service from Converge ICT. It requests personal and contact information from applicants, as well as residential and service details. Applicants must select an internet plan and installation fee payment terms. Requirements include proof of billing, valid ID, and a Google Maps screenshot pinpointing the service location. By submitting the form, applicants agree to terms of service and that equipment will remain Converge's property.

Uploaded by

renton locker
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Thank you for choosing Converge ICT!

Please fill-out the information below so we could


process your application and have it installed the soonest.
Note: Please e-mail this file back to [email protected]
Personal Info
First Name:
Middle Name: Residential Info
Last Name: Home Ownership Type(Owned or Rented):
Date of Birth: # of years in residence:
Nationality: Are you in a building?:
Gender: Are you in a gated subdivision?:
Civil Status: Where did you learn about Converge:
Name of Spouse(If married):
Company: Service Info (If billing info is different
Designation / Position: please indicate separately)
Branch / Location: Region:
Province:
Mother’s Maiden Name Municipality / City:
First Name: Barangay:
Middle Name: Building:
Last Name: Subdivision:
Street:
Contact Info House/Floor/Room No.:
Mobile Number:
Landline Number:
Email Address:
Plan (Refer to the table below for available plans):
Installation Fee (Underline the preferred terms): One Time Payment(P2,500) or Installment(P3,000)
REQUIREMENTS
I. Proof of Billing

(Insert Here)

II. Valid ID with Signature

(Insert Here)

III. Screenshot of location from Google Maps


(Pin on the specific location. Provide coordinates)

I hereby subscribe to the Internet service of Converge ICT Solutions, INC., subject to my payment of
installation and equipment fee and subscription deposit which is non-refundable in the event that my
subscription is pre-terminated prior to the completion of the agreed prescribed terms after initial
installation. I agree that my subscription herein is intended based on my subscription terms and
conditions as stipulated in the attached SUBSCRIPTION AGREEMENT form. I further agree that all
equipment installed in my designated address shall not be transferred to any other location and shall
remain the property of Converge and in the event of disconnection will be voluntarily surrendered to
Converge without the need of any demand. I certify all information is true and correct to the best of my
knowledge.

 I agree

 I disagree

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