APPLICATION FOR CONNECTING (INSTALLATION) TO JCS NETWORK

You will be required to fill in this application in English language
           
I. I, the undersigned, Mr/Mrs

The address where I solicit the connection "the Site":

City District

Street Block of flats/House number

Postal Code  P.O. Box

Telephone    Fax   E-Mail

Identity Certificate:

National ID number/Residency permit
Or
Passport number and issuing country

Registration number at the Company Control Department (for companies)

I with the signature fixed herein under I explicitly solicit the connection to JCS cable network at the above mentioned address. In addition I declare and warrant that I have good and valid title, lease or benefit rights to the Site and I undertake to indemnify JCS in case it became liable for any one because of any misrepresentation or incorrect information.

II. JCS SERVICES OFFER (you are requested to mark the service you desire)
Cable television 
Fiber Link & Internet  

Name and given name

Signature

Date