CO N V E R G E SERVICE APPLICATION FORM x»: B

> Application Type: M Residential O Commercial

> Date: 2/12/21
First Name: MICAH MiddIe Name: GOMEZ Last Name: DEJUMO
Date of Birth (MM/DD/YYI: 12 /’ 11 / 1995 Gender; Male @Female Civil Status. OSingle @ Married O5eparated @Widovv
v Full Mother's Maiden Name: DIANA MARFEL GOMEZ > Name a* Spouse (if married): EDDIE RODRIGUEZ DEJUMO
> Nabonalify: FILIPINO Mobile No./Tei. No.: 09070597093 > E-mall Add! micsdejumo@gmail.com

Industry T.I. N.:

Compeny’s Authorized Pepresentatrve: „„ „„„,„ Gender. @ Male @ Femele Deparlment.:
Company ID No.: Mobile No,:
Lan0llne No.: E-mall Add:

I nc electronic ñ\atcrricnt of xccD:unt ano otncr notices via email and S MS enall apply th ñ same Iago! effects, validity ano ñfforccaDility.
Prl mary E malI A ddrc ss' 1. Prlm a ry Mob IIe No.: — —
Secondary E-mall Acldress: 2. Secondary Moblle No.: — —
+ For any ‹zhangr° -.n run lnlormallnn mrnllnnñn ahme, kinn y v bit its a\ https:/.'arr:ment tJpr1a!n rnri'/°rg°.ill.rom ’

RESIDENTIAL
> Home Ownership: M Owned El Livlng with Relatives M Mortgaged M Rented Company—paid M No MYes ‹Please attach Guarantee Letter)
> Years of Resloency: 3 months Name of Lessor/owner: Ariel Senabuen Contact No/s.: N/A
> House/Room No. /FIc›cir: BLK. 11 LOT 17 ApartmenVCompound/Building, Street: KALAW STREET
> Subdlvlslon: PUROK 12, UNIT 5 Barangay. COMMONWEALTH Munlclpally/City: QUEZON CITY
Province: Zip code: 1121

COMMERCIAL
Room No. /FIoor Compound/Buiiding: Street:
Subdiv1sion: Barangay: Mut›lclpality/City:
Province: Zip code:

RESIDENTIAL PLANS COMMERCIAL PLANS

I_j FIBERX 1500 Php 1.500 Php 125/24mo. a IBIZ PLAN 10 Php 4,000 Php 2OB/24mc | O MICROBIZ 1OD0 Php 2,000 Php 125/24mo
O FIBERX 2500 Php 2,500 Php 125/24mO O IBIZ PLAN 20 Php 6,000 Php 125/2‹*o. | O MlCROBiZ 3o00 Php 3,000 Pip 125/z4nio
O FIBERX 3500 Pip 3,500 Php 125/12mo.
a IBIZ PLAN 30 Php 9,000 Php 83/Demo. 'with • *a^‹ ^ayme optlon a‘ Phe 2.soo
If FIBER Xtreme 4500 Php 4,500 WAIVED
a IBIZ PLAN 40 Pip 12,000 Php 83/24mo. i. Hicro6iz palate is not recamended for internet
O FIBER Xtreme 7000 Php 7,000 WAIVED cafe.
a IBIZ PLAN 50 Php 15,000 WAIVED 2. Ideal for not more thap S users / commuters.
^ •« prl es are VAT iiJcIouix’e.

ar›d£Tpizsaforr|anJ5oo.vyaved ns:alat‹enreeforPsnsP5ooano7ooc. Php3,ooo-wiBlzPlDn 2o.and eP2ooGforlBizP|ansTD84o.

Minimum sp-eed is 3O@ of burst spe-=d at 80% service reliability Wal vcd Insta Ibution Fee for F'lan 5O'
Public l9 0 Yes O > 0 OUTRIGHT
No Others: O STAGGERED
Others:

All prices are VAT Inc lusive IEJ4months

RESIDENTIAL
D Government-issued ID
Id Proof of biiling l›
notHia1es
n Proof of income iz •au• i•u
+ Permit T BID/COIL
If renteo
O Lease contras t or
Endorsement from lessor
O Government Issued ID
Single Proprietor
Ld Business or Nayors Permit
f4ANDATORY REQUIREMENTS
COMMERCIAL
O Government Issued JD of Representative
Partnership/Corporation Foreign Embassy
z SEC Registration and Business/Nayor‘s Ld Authorized Letter I am Ambassador
c BIR/COR m Proof of Identification horn Auth0rlzed
¿ Corporate Secretary’s Certificate ra squared› Signatory

Where did you learn abaut our offe« g Billboard / Ej Leaflets ,’ Radio / LJ TV EJ Internet / Cj Friend Referrals / Others
This portion is to be filled-out by custornei service representative.
Account No.: for Internet: - O.R No.
Special Instruction- Salesman code: INH-002-009

unDeRTAKlNG
I hereby subscribe to tho Internet Sender orConverge ICT So/uxons, /NC., subject to my payment o/ Installation & Ee»lpment
Fee and Subscription Deposit wfilch nre nor›-'•.Funda6/e in tfie e.vent thnt my subscAptlon. Is pre.•te.rmlnal‹• prior to the
completion ofrhe ag/•eed yrescr/ded teas acer /.n/ca/ nsta//ation. / agree teat my subscription hereln Is Intended based on
my sr 6scrijorion tem1s ancf condi/Jorts as slips /arecf ml rue atrac/1ed TERMS AND C6AD/WONS form. / lust-her agree MICAH G. DEJUMO
thai' a.'I equipment installed in my designated address snail not se rransFerred to any otner locauon aha shall remain roe
property of Converge and In the eveni ofc//sconnecr/on will be no/cintar/\ sr/rrenaerea to Conve+ge wlllnout tne need of
any dern.and. App#canCsSl#npCureoverPrfn›edName