Wireless Order Form

Note: Please make sure that your PC or network is free from hardware or software errors or conflicts prior to the installation. In the event that the subscriber’s PCs is not working properly, the KansasNet technician will use his/her laptop to make sure the connection is good and advise the subscriber that he/she will need to get their PC repaired prior to installation.

(To be completed by subscriber)

Customer Self Install:

Technician Install:

Installation Total: $_______________

Monthly Service: $_______________

Commitment: ________ Months

Date _________________

(Check one of the following)

Single PC

2-4 Devices

Large Network

(Basic network information)

Type of PC(s) (brand, specs, etc. ________________________________

# of PC’s ________

Operating System(s) ________________________________

Existing Network Interface Card (NIC) Yes No

Subscriber Information

Subscriber Name __________________________________________

Service Address __________________________________________

City, State, Zip __________________________________________

Contact Name __________________________________________

Contact Phone Number __________________________________________

Requested Install Date ___________________________

I, the undersigned realize that this is an obligation for KansasNet Wireless Service for the term of 12 months. I am authorized to, and do agree to commit the below signed Subscriber to the payments (based on my selections listed above) for this term. This monthly payment will be made by AutoDebit or prepaid. I realize that failure to complete my service term commitment will result in a penalty fine equal to the number of months remaining in the agreement multiplied by the monthly service rate. I also acknowledge that the equipment I am provided for usage of this service is the sole property of KansasNet, and that I am liable for damage caused by tampering with, or improper usage of this connection. I also acknowledge that I have seen, and agree to the terms in the document "Terms of Access," which describes a usage policy for the connection.

Subscriber Name (Printed) _____________________________________

Subscriber Signature ______________________________ Date________________

Installation Information

(This section is information to be filled in by KansasNet technician)

Date:______________

Notes to installer: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Equipment	Description (serial #, length, any notes)
Router (or card)
Misc. Patch Cable
Cable
Lighting Arrester
Antenna Kit (including poles & tie downs)