“Bringing the World to your Home”

Moonglow, Tandag, Surigao del Sur

Tel Nos.: (086) 211-3901 Cel. No.: 09478919411
E-mail: mscatv_tandag@yahoo.co.uk

APPLICATION FORM
Account No.:_______________
SUBSCRIBERS INFORMATION:
Subscribers Name:________________________________________________________________
Location:________________________________________________________________________
Billing Address:___________________________________________________________________
Telephone/Cell phone Nos.:________________________
Class of Service: ______Residential ______Commercial ______Government
Type of Service: ______Main ______Extension
For Application of Extension with different account nos.: (pls. specify)
Name of Main Line Subscriber:_________________________________________
Account no. of Main Line:______________________________________________
Conforme:________________________

__________________________
Applicant’s Signature Over Printed Name
______________________________________________________

TECHNICAL/ESTIMATE DETAILS
RG-6 Wire _________ IPTV STB __________
RG-6 Connector _________ EPON ONU (modem) __________
Straight Connector _________ UTP Cable
2way Splitter _________
3way Splitter _________
SC/APC Connector _________ ESTIMATED BY:
SC/UPC Connector _________ INSTALLED BY: _______________
Mini Node _________ DATE INSTALLED:
Fiber Optic Wire _________

BREAKDOWN OF CHARGES: Approved for Installation by:

Installation Fee(Main)_ _ _ _ _ _ _ Php ___________
Installation Fee(Extension)_ _ _ _ _ ___________
Excess Fiber Optic(10.00/m)_ _ _ _ ___________ _______________________
Excess Dropwire(10.00/ft) _ _ _ _ _ ___________ Customer Service
2 way Splitter_ _ _ _ _ _ _ _ _ _ _ _ ___________
3 way Splitter_ _ _ _ _ _ _ _ _ _ _ _ ___________ _______________________
RG-6 Connector_ _ _ _ _ _ _ _ _ _ _ ___________ Billing & Settlements
1 set Straight Connector_ _ _ _ _ _ _ ___________
SC/APC Connector_ _ _ _ _ __ _ _ _ ___________ _______________________
TOTAL INSTALLATION COST Php ___________ Technical Head
O.R. Number :___________
Date Paid :___________
Teller’s Signature:___________ _______________________
Manager

8/28/2021 5:42 a8/p8 jacque.llo