JB-Nets Broadband Services
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Customer Signature Card
Reason for visit
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Account #
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I have received services provided by JB-Nets.
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Yes
No
I declined to recieve a copy of an estimate/paperwork.
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No
Current customer enabled Spam/Robo Blocker on VoIP?
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Yes $4.95/mo.
No
I have agreed to opt into the Equipment Coverage Plan and was given a copy of the Equipment Coverage Plan Terms.
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*Disclaimer: If you have signed a Signature Adoption Paper authorizing someone to sign on your behalf, you are responsible for whatever changes they make on your account that may incur charges.
Customer Signature
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Customer Printed Name
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Date
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Billing Dept. Only Below
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Autopay
CC Autopay
ACH Autopay
Memo on Invoice
Entered in Netsuite
Pro-Rated Invoice (if needed)
Update Mem. Trans.
Tech. Initials
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Customer Signature Card
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