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GENERAL INFORMATION
Name
*
Service Address
*
Parish
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Postal code
*
House Directions
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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
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PAYMENT INFORMATION
Choose credit/debit card payment option
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Credit Card
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Master Card
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Name:(As it appears on card)
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Please charge my card on the 15th of each month for my balance due:
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Card
*
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*
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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