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GENERAL INFORMATION

Name *

Date of Birth (MM-DD-YYYY)

Photo ID:License No

CLIENT INFORMATION

Home Phone

Cell Phone

Email *

Billing Address

Parish

Postal Code

BILLING INFORMATION

Card Payment Option:* Credit Card Debit Card Master Card Visa Amex

Name *

Expiration *

Auto - payment on the 10th of each month Yes No

Card *

CVV *

MOBILE PORTING INFORMATION

Current Service Provider *

Account Type * Postpaid Prepaid

Account No (Not your telephone number, find it in your digicel/cellone/BTC bill) *

Phone No *

Agent Name *

LIVENET PRODUCT

Product Name	Plan	Plan Price
Senior Plan	Unlimited Local Calling	$42
Student Plan	Unlimited Local Calling	$50
Economy	2GB Data	$75
Economy+	5GB Data	$99
Business	10GB (US Roaming)	$125
Business+	15GB (Worldwide Roaming*)	$165
Unlimited	∞GB(Worldwide Roaming*)	$199
Other		-

CONTRACT AGREEMENT TERMS

By signing below, I agree to the terms and conditions as directed by LiveNet Bermuda. All payments are to be made within 30 days of the prescribed billing cycle to ensure that services remain active. Should you wish to discontinue services with LiveNet kindly be advised that 30 days’ notice is required.

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