Customer Internet Installation Form

Legacy Tech Services LLC

Internet Installation Form

Full Name Phone Number Email Address Installation Address Is this your residence or a business?

Residence Business

If business, name of business Is the property owned or rented?

Owned Rented

Do you have permission for installation (if rented)?

Yes No

Landlord's Name (if applicable) Landlord Contact Info Preferred Installation Date Preferred Time Preferred Router Location Select Your Internet Plan

$75 - 10–20 Mbps $99 - 20–50+ Mbps $115 - 50–200 Mbps

Authorization

I confirm that the above information is correct. I give permission for Legacy Tech Services LLC to install internet services at the address provided.

Signature Date