Residential Service Change Form

Residential Service Change Form
Customer Name*
Red Bolt Account Number
Service Address*
Phone*
Email Address*
example@example.com
Please indicate the type of account change in the appropriate box below. (If you are adding or cancelling an IP address, choose the upgrade or downgrade option.)*

UpgradeDowngradeAdd DeviceReturn Device
If you would like to change your service package or add a device, please choose from the following options.*

Essentials Plan (100 Mbps) – $59.95/monthFamily Plan (300 Mbps) – $69.95/monthGamer Plan (600 Mbps) – $79.95/monthGiga Plan (1,000 Mbps) – $89.95/monthManaged Wireless Router (Recommended)– $7.00/month5Ghz WiFi Extender – $3.95/monthPublic IP Address – $3.95/month
If you are returning or exchanging a router, what is the reason?
By changing my service plan and/or adding equipment/additional services, I understand the changes and charges as shown below, plus tax, will be reflected in the next billing cycle. By signing this form, I understand that a $20 cleaning fee plus tax, per device, will be assessed if the equipment needs cleaning. If the equipment is returned unusable (e.g. returned without power cord or damaged) I am responsible for full retail value of the equipment.
Signature*

Clear
Date*

MonthDayYear
Date
1821 Clif Lear Ave. / PO Box 1087 / Grants, New Mexico 87020 / redboltbroadband.com / Ph: 505.876.2005 / Fx: 505.287.2234
Should be Empty: