IPTV Service Application

Customer Information

Customer Name
Service Address
Daytime Phone
Cellular Phone
Email address
Billing Address
Social Security #
Drivers License #
Account Password (To verify account information)
Date Service is Requested

Available IPTV Services

Basic Package
Premium Movie Channels
Expanded Package
Digital Video Recorder (DVR)
Additional Receiver
Whole Home DVR

In order to provide IPTV Service to subscribers, it is my understanding that I will be allowing facilities and personnel on my property if owned by myself, or will get approval from the owner.

I agree that any leased equipment is the property of the Northwest Communications, shall be subject to monthly rental charges, and shall be returned upon termination of service in good working condition.

In making this application, I agree to pay the bill in a timely manner and follow the rules and regulations as established by Northwest Communications or its subsidiary. All prices are subject to change.

Customer Signature __________________________________

Date __________

Northwest Communications
116 Harriman Ave N
Amery, WI 54001