THE TOTAL SOLUTION PROVIDER

Dctech Bldg. Shanghai St., Matina Aplaya, Davao City

Tel No. 221-2380 / 81 Fax No. 221-2382
APPLICATION FORM

I. GENERAL CLIENT INFORMATION

✓ Account Name: Magaway, Rolando E. Date:
✓ Name of Owner/ Contract Signatory: Magaway, Rolando E.
✓ Contact Person Magaway, Rolando E.
Contact Details
✓ Landline No.:
✓ Mobile No.: 09455112781
✓ Email Address: ramagaway@gmail.com
Address
Rented Owned
✓ Business:

Rented
✓ Residence : Cadena De Amor, Brgy Poblacion Tantangan Owned
X
So.Cot.
✓ Billing address: Rented
Cadena De Amor, Brgy Poblacion Tantangan Owned
So.Cot.

Requirements Checklist
1 Proof of Billing ✓ 2 Valid ID’s
(FOR SALES)

SERVICE OPTIONS:
INTERNET INTRANET
OTHER REMARKS COORDINATES: 6.6111082,124.7464142
PACKAGE CODE: SP7R22208 MRR: 1,199
MAX: 100MBPS OTC:150m Free installation
CIR: 512 KBPS TERM: 24 Months
X CASH CHECK
The undersigned hereby confirms that the above information are true and correct and may subject to verifications at DctecH’s option

✓ Magaway, Rolando E. ✓
AUTHORIZED SIGNATORY OVER PRINTED NAME DATE

SALES REPRESENTATIVE AGENT: DATE

(FOR ACCOUNTING)

DESCRIPTION PAYMENT SCHEDULE

Initial 2nd to 4th 5th to 12th
Monthly Subscription
One Time Cost
Excess Rolls
Other Charges
Advance
Deposit
12% VAT
TOTAL CASH OUT

ACCOUNTING SIGNATURE
(FOR TECHNICAL)

Date Activated: Modem Serial Number:

Actual Wires Used:
OTC (wireless):

TECHNICAL DEPARTMENT
(FOR ACCOUNT MANAGEMENT)

Contract Discussed to: Accepted by:

SIGNATORY OVER PRINTED NAME/ DATE SIGNATORY OVER PRINTED NAME/ DATE

Account Management:
SIGNATORY OVER PRINTED NAME/ DATE