Thank you for choosing Converge ICT!

Please fill-out the information below so we could

process your application and have it installed the soonest.
Note: Please e-mail this file back to application.convergebaguio@gmail.com
Personal Info
First Name:
Middle Name: Residential Info
Last Name: Home Ownership Type(Owned or Rented):
Date of Birth: # of years in residence:
Nationality: Are you in a building?:
Gender: Are you in a gated subdivision?:
Civil Status: Where did you learn about Converge:
Name of Spouse(If married):
Company: Service Info (If billing info is different
Designation / Position: please indicate separately)
Branch / Location: Region:
Province:
Mother’s Maiden Name Municipality / City:
First Name: Barangay:
Middle Name: Building:
Last Name: Subdivision:
Street:
Contact Info House/Floor/Room No.:
Mobile Number:
Landline Number:
Email Address:
Plan (Refer to the table below for available plans):
Installation Fee (Underline the preferred terms): One Time Payment(P2,500) or Installment(P3,000)
 REQUIREMENTS
I. Proof of Billing

(Insert Here)

II. Valid ID with Signature

(Insert Here)

III. Screenshot of location from Google Maps

(Pin on the specific location. Provide coordinates)

(See sample below)

I hereby subscribe to the Internet service of Converge ICT Solutions, INC., subject to my payment of
installation and equipment fee and subscription deposit which is non-refundable in the event that my
subscription is pre-terminated prior to the completion of the agreed prescribed terms after initial
installation. I agree that my subscription herein is intended based on my subscription terms and
conditions as stipulated in the attached SUBSCRIPTION AGREEMENT form. I further agree that all
equipment installed in my designated address shall not be transferred to any other location and shall
remain the property of Converge and in the event of disconnection will be voluntarily surrendered to
Converge without the need of any demand. I certify all information is true and correct to the best of my
knowledge.

 I agree

 I disagree