Request for Service Change Form

Request for Service Change Form

Revised 10/1/24
This form is to be used ONLY for Red Bolt Broadband service. Any changes to an existing CDEC electric account must be made separately on the form designated for such changes.
Customer Name*
Red Bolt Account Number
Service Address*
Phone*
Email Address*
example@example.com
By changing my service plan, I understand the changes and charges as shown below, plus tax, will be reflected in the next billing cycle.
Indicate the type of account change in the 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.*

$49.95/month: 100/100 Mbps$59.95/month: 300/300 Mbps$89.95/month: 1000/1000 Mbps (1 Gig)$7.00/month: Wireless Router Rental$3.95/month: 5Ghz WiFi Extender$3.95/month: Public IP Address
By adding or returning equipment, I understand the charges above, plus tax, will be reflected on my monthly bill from the date on this form going forward.
I am ADDING a router and/or Wi-Fi extender.I am RETURNING a router and/or Wi-Fi extender.
FSAN number on ADDED router and/or Wi-Fi:
FSAN number on RETURNED Router and/or Wi-Fi Extender:
Reason for Return/Exchange
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, (i.e., returned without power cord or damaged), I am responsible for the full retail value of the equipment.
$20.00 cleaning fee, plus tax required?

YesNo
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: