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Business Residential

Sales: 441-400-5983

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GENERAL INFORMATION

Name *

Service Address *

Parish *

Postal code *

House Directions *

BILLING INFORMATION

Billing Address

Parish

Postal Code

CONTACT INFORMATION

Home Phone

Work Phone

Employer

Mobile *

Email *

IDENTIFICATION INFORMATION

Photo ID:License No

Date of Birth (MM-DD-YYYY)

or Passport No

STATEMENT DELIVERY

Email Account *

PAYMENT INFORMATION

Choose credit/debit card payment option * Credit Card Debit Card Master Card Visa Amex

Name:(As it appears on card) *

Expiration *

Please charge my card on the 15th of each month for my balance due: Yes No

Card *

CVV *

LIVENET PRODUCT

PRODUCT NAME	COST
100MB Internet & Home Phone	$175
100MB Internet Home Phone & Live TV	$200
100MB Internet & Live TV	$189
50MB Internet & Live TV	$169
50MB Internet & Home Phone	$154
50MB Internet, Home Phone & LiveTV	$180
50MB Internet only	$119
100MB Internet only	$140
LiveTV Only	$50
Home Phone Only	$50

INSTALLIATION CHARGES

Full Mesh - $225 | Additional Individual Mesh - $75 | TP Link Router - $100 | Fire Stick - $100 | TV BOX - $200

CUSTOMER NOTES

Customer Notes

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