ALAN CAHILL   BROADBAND SERVICES AGREEMENT FORM

PLEASE FILL OUT THIS FORM AND PRINT A COPY BEFORE SUBMITTING IT.

ANY QUESTIONS PLEASE CALL  085-863-9959

Section One Site details and Customer information
This agreement is between Alan Cahill , Brownsmills, Kinsale, Co. Cork And
Company Name	*
Address	*
Contact Name	*
Telephone number	*
Email address	*
Fax number
Site information
Section Two Service Details THIS SECTION WILL BE FILLED OUT BY VENDOR
Site Ref
Service code
Service description
Quantity
Requested Service date
Billing period
Min. Period (months)
One off Installation charges ex.VAT
Recurring rental ex. VAT (per billing period)
Tariff Code
Charge Total
Section 3 Customer Details
Company Name	*
Registration Number	*
Registered Office/Trading Address	*
Number of years trading	*
Telephone	*
Fax number
Section 4 Property Details
Please check the box for your business type	*	HOTEL GUEST HOUSE / B&B STAFF / WORK CLUB SPORTS / SOCIAL CLUB SCHOOL / COLLEGE PUBLIC HOUSE HOSPITAL SHOP NURSING HOME BETTING OFFICE FINANCIAL INSTITUTION REGISTERED CHARITY OFFICE OTHER
Section 5 Billing Instructions Direct Debit
Billing Account Name	*
Billing Address (if different from the installation address)
Billing Contact	*
Telephone	*
Email	*
Direct Debit BANK NAME	*
Direct Debit BANK ADDRESS	*
Direct Debit BANK SORT CODE	*
Direct Debit BANK ACCOUNT NUMBER	*
EXACT NAME ON BANK ACCOUNT	*
Section 6 Agreement by Customer : The customer hereby agrees to accept and use the services subject to Alan Cahill's standard terms and conditions which have been provided to the customer and which are available on request. Services supplied subject to Status, Site Survey, Wayleave and network Availability.
For and on behalf of the customer: PLEASE TYPE NAME and DATE	*
Signature: By typing your name and date in this field you agree to be bound by the terms and conditions	*
Position	*
Section 7 Agreement By ALAN CAHILL: ALan Cahill hereby agrees to provide the services as specified according to the terms and conditions of this agreement which have been provided to the customer and are available on request.
For and on Behalf of ALAN CAHILL: Account Manager: Alan Cahill: Telephone 085-86399859
Signature : and Date		Alan Cahill
ALL APPLICANTS ARE SUBJECT TO CREDIT VETTING. SERVICES ARE SUPPLIED SUBJECT TO STATUS. This agreement sets out the terms on which Alan Cahill whose business address is at Brownsmills, Kinsale, Co. Cork will supply to you the "Services" and the "Services Equipment"as specified on the terms shown herin. DATA PROTECTION ACT 1988: Alan Cahill may use any personal information provided by the customer for the purposes of administering the customers account, providing the customer with services and providing information about its services. Alan Cahill may disclose the customers personal information to other members of their group of companies and to its sub-contractors for these purposes. From time to time Alan Cahill carries out research on its customers opinions about its services. With the customers agreement Alan Cahill will use the customers opinions anonymously and disclose it to research organisations for this purpose.