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RESIDENTIAL WIRELESS BROADBAND APPLICATION FORM
* Required

PERSONAL INFO:
Physical Address:
* First Name: * Last Name:
Company (if applicable): * House Number:
* Street Address: * City:
* Postal Code: Work Phone:
* Home Phone: Cell Phone:

Billing Address:
If different than your physical address.
PO Box: City/Town:
Province: Postal Code:

Driving Directions:

Additional Comments:

RESERVE INFO: (for First Nation residents ONLY)
* Reserve Name: * Reserve Community:
Treaty # / Exemption:
(Required or GST will be charged)
Must be a 10 digit Status #.

 
Teacherage?
Yes No

Health Centre Residence?
Yes No
 

SUBSCRIPTION PLAN:  
5Mbps (Residential)
Installation Fee*: $250.00+GST
Charge: $65.00+GST/month
Residential with VOIP
Installation Fee*: $250.00+GST
Charge: $90.00+GST/month
*Requires a VOIP router - $150.00+GST
10Mbps (Residential)
Installation Fee*: $250.00+GST
Charge: $100.00+GST/month
Residential with VOIP
Installation Fee*: $250.00+GST
Charge: $125.00+GST/month
*Requires a VOIP router - $150.00+GST
MONTHLY STATEMENTS:
How would you like your monthly statements sent to you?
Via Email
Current Email Address:
*

Mailed to my residence ($2.75 FEE)


NOTE: An Administration Fee of $2.75 (no GST) will be charged to your account on a monthly basis if you choose to have your invoices/statements mailed to your mailing address. There is no charge for email.

ADDITIONAL HARDWARE REQUEST/OPTIONS:
Please check off the boxes for additional hardware and or software and your Arrow Technician will install and configure the following you have chosen upon installation.

Network Router with VOIP capacity -- $150.00*
Allows you to plug your current phone into the router for VoIP services and will provide wifi.

EQUIPMENT OWNERSHIP:
The Customer agrees that all equipment will remain the property of Arrow unless agreed otherwise. The Customer agrees not to sell, transfer, lease, or assign any interest in or mortgage or encumber all or any part of the equipment provided by the Company. The Customer agrees to pay Arrow the full cost of repair and/or replacement if damage occurs that is not the fault of Arrow.

Please check the below box and type in your full name if you agree with the ownership terms.

I AGREE TO THE ABOVE TERMS

* Full Name:

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 will receive all Arrow by email at the end of each month, to the Arrow email account I was provided at the time of install.
  • 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 Arrow. If you cancel your internet service Arrow will remove the subscriber unit.
  • I will be contacted by an Arrow Installer to arrange an installation time.
  • Arrow will cooperate with law enforcement if a criminal violation is suspected













Arrow Technology Group
Santa Fe Plaza - 18236 102 Ave
Edmonton, Aberta T5S 1S7
Phone: (780) 701-4050
Fax: (780) 451-6050

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