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Broadband Service Agreement Form
Please fill the form below
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The undersigned member of Valley Electric Association, Inc. ("VEA"), hereby applies for Residential Broadband Internet Service of 25 Mbps @ $49.95 per Month for wireless or 50 Mbps @ $49.95 per month for fiber
(depending on the service available in your area). By signing this document, the undersigned agrees to the terms of VEA’s Retail Member Master Service Agreement,
VEA’s Acceptable Use Policy, and any other Rules and Regulations now in effect or which may be hereafter amended, adopted or repealed. If your electric membership is a joint account, both members must sign this application.
Applicant:
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VEA Account Number:
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VEA Member Number (Account Number minus the last 3 digits).:
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EMail:
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Please enter valid email address
Social Security Number:
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Driver's License Number:
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Phone:
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Invalid phone number.
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2nd Phone:
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Employer:
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Work Number:
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Co-applicant:
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Co-applicant E-mail:
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Please enter valid email address
Social Security Number:
Invalid number !.
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The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Driver's License Number:
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Phone:
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Invalid phone number.
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2nd Phone:
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Employer:
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Work Number:
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Physical address of property:
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Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
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Brazil
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Cameroon
Canada
Cape Verde
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Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
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Estonia
Ethiopia
Fiji
Finland
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Guyana
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Hungary
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Ireland {Republic}
Israel
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Jamaica
Japan
Jordan
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Kosovo
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Liberia
Libya
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Lithuania
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Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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Zip Code
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Mailing Address:
Address Line1
Address Line2
Land Mark
City
State
Country
Please select country name
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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Zip Code
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Do you rent or own? (If you rent, your landlord must complete the approval form.):
Rent/Lease
Own
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Do you give VEA consent to install fiber lines, antennas, equipment and devices at the residence?:
Yes
No
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During installation it may be necessary to penetrate the structure of the residence to install the equipment. Do you give VEA consent to perform this as needed:
Yes
No
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Date:
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The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Applicant's Signature:
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Date:
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The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Co-applicant's Signature:
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Other info (locked gates, dogs, etc.):
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The installation date for service at your residence is dependent upon your location and VEA’s build-out schedule. Signing this agreement does not guarantee the actual installation date.
It is your responsibility to take appropriate precautions to secure your own network by installing and maintaining anti-virus and anti-malware software.
VEA does not assume any responsibility for any content stored, accessed, or transmitted using VEA broadband services. You are solely responsible for all content offered or received using VEA broadband services.
VEA Landowner/Landlord Approval Form
Dear Applicant,
Thank you for choosing Valley Electric Association, Inc. as your wireless internet provider! To ensure you have a smooth installation experience, if you do not own the premises where service will be installed,
we require that you obtain landowner/landlord approval prior to installation.
Installation of VEA equipment may involve modifications to the premises. While these modifications are often minor, standard professional installation many times includes drilling holes in order to run cable and attach equipment
securely to the outside of the premises. Any such type of modification may be forbidden pursuant to the terms of your lease/rental agreement or may require pre-approval by the landowner/landlord.
Please be advised that landowner/landlord approval is required before any modifications to the premises.
Please request that the landowner/landlord, or its authorized representative, complete the section below to acknowledge authorization for the installation and provide this signed form to Valley Electric Association, Inc
at the address below before scheduling an installation.
By presenting this form to Valley Electric Association, Inc., you are granting permission to install VEA equipment and are releasing Valley Electric Association, Inc.
from the obligation to remove your system after it is installed. This signed installation permission form releases VEA (including any installation technician) from any liability related to damages your
landowner/landlord may claim as a result of an alleged violation of your lease/rental agreement as it relates to the installation of your new Valley Electric Association, Inc. equipment.
Should your landowner/landlord only approve the Valley Electric Association, Inc. installation subject to special requirements that make the actual installation more expensive
(or exceed what VEA offers as part of its standard professional installation), you will be asked to pay a corresponding charge, to be agreed upon by you and Valley Electric Association, Inc.,
for the additional services. Upon installation, all equipment is still Valley Electric Association, Inc.
equipment and proper care must be taken of the equipment. Any damages to the equipment will be charged to the subscriber.
Please remember that technical issues may still prevent installation of your VEA equipment. Though this is rare, unforseen challenges may prohibit installation of VEA equipment.
I,
Landowner/Landlord/Authorized Representative ,:
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, hereby authorize
Tenant/Lessee/Applicant :
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to install VEA equipment at
Location address .:
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Signature of landowner/landlord/authorized representative:
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Date:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
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