STEP 1 Application Form and Plan Details

SELECTED PLAN and Speed:

Please SELECT:

CONVERGE FiberX 1500 up to 200mbps (Payment of P1,500 Upon installation and 125 billed to account) - Monthly Internet Bill P1,500 + 125 for 24 months CONVERGE FiberX 2000 up to 400mbps (Payment of P2,000 Upon installation and 125 billed to account) - Monthly Internet Bill P2,000 + 125 for 24 months CONVERGE FiberX 2500 up to 600mbps (Payment of P2,500 Upon installation and 125 billed to account) - Monthly Internet Bill P2,500 + 125 for 24 months CONVERGE FiberX 3500 up to 800mbps (Payment of P3,500 Upon installation) - Monthly Internet Bill P3,500 for 24 months CONVERGE FiberX 1250 up to 50mbps (Payment of P1,250 Upon installation and 125 billed to account) - Monthly Internet Bill P1,250 + 125 for 24 months CONVERGE BIDA FIBER 888 Deferred (Payment of P888 Upon installation) - Monthly Internet Bill 988 for 18 months (35mbps for 6 devices only) CONVERGE BIDA FIBER 888 Outright (Payment of P2,388 Upon installation) - Monthly Internet Bill 888

1. First Name:

2. Middle Name:

3. Last Name:

4. Date of Birth:

5. Gender:

6. Mother's Maiden Name: First name, Middle name, Last name

7. Civil Status:

8. Name of Husband or Wife (if married): First name, Middle name, Last name

9. Citizenship:

10. Primary E-mail Address:

10 a. Secondary E-mail Address:

11. Primary Mobile No:

12. Secondary Mobile No:

13. VERY IMPORTANT Please indicate your COMPLETE ADDRESS:

13 a. Home Ownership:

Owned Living with Relatives Mortgage Rented

13 b. Years of Residency:

14. VERY IMPORTANT your House number and Purok ***

15. NEAREST Landmark:

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