1. CUSTOMER INFORMATION Full Name Gender MaleFemaleOther Date of Birth Nationality ID Type Ghana CardPassportDriver’s LicenseOther ID Number Email Address Mobile Number Alternative Number 2. SERVICE LOCATION House Number / Apartment Street Name Area / Community City / Town Region GPS Address Landmark 3. PACKAGE SELECTION Selected Package BasicStandardPremiumCustom Installation Date Preferred 4. EQUIPMENT ONT/Router Quantity ONT/Router Ownership CompanyCustomer ONT/Router Serial Number Wi-Fi Extender Quantity Wi-Fi Extender Ownership CompanyCustomer Wi-Fi Extender Serial Number Other Equipment Type Other Quantity Other Ownership CompanyCustomer Other Serial Number 5. BILLING DETAILS Billing Cycle MonthlyQuarterlyAnnually Preferred Payment Method Mobile MoneyBank TransferCashOther Billing Contact Name (if different) Billing Email Billing Phone 6. TERMS & AGREEMENT I confirm that the information provided is correct. I understand and agree to the FTTH service terms, installation fees, and monthly subscription charges. I agree to return any company-owned equipment upon service termination. Customer Signature (Type Full Name) Date Sales Agent Name Sales Agent Signature (Type Full Name)
