To download the form click here Customer NameLTC NoSON NoPlease to be completed in BLOCK CAPITALSPremises NoPremises NameSub PremisesStreet NamePost TownPost CodeContact MobileContact TelephoneContact NameContact Email Delivery Address if differentPremises NoPremises NameSub PremisesStreet NamePost TownPost CodeContact MobileContact TelephoneLine InstallationMaintenance PackRentalLevel 3Level 4ADSL ServicesNoneLT Business 100GB — 24Mbps(Down) - 1.3Mbps(Up)LT Business UL — 24Mbps(Down) - 1.3Mbps(Up)LT BASIC BB — 24Mbps(Down) - 1.3Mbps(Up)LT PLUS BB — 24Mbps(Down) - 1.3Mbps(Up)Fibre ServicesNoneLT FTTC UL — 40Mbps(Down) - 2Mbps(Up)LT FTTC UL — 40Mbps(Down) - 10Mbps(Up)LT FTTC UL — 80Mbps(Down) - 20Mbps(Up)LT MAX BB — 40Mbps(Down) - 10Mbps(Up)LT MAX PLUS BB — 80Mbps(Down) - 20Mbps(Up)Do you have a server and need a Static/Fixed IP address Yes No Number of additional IP addresses required Yes No Do you wish to use your existing router Yes No Are there any 3rd party services on the line (Fax, Alarm, EPOS etc...) Yes No Does your e-mail address end with your company’s name Yes No Do you have your own IT support Yes No Will you require our IT support from Logics Technologies? Yes No The customer is also responsible if they choose to use their own router/modem, for the support of that router/modem and associated cabling and that Logics Broadband Helpdesk will only support up to that router/modem. The customer is also responsible for any extra cabling that may be required in order for their equipment to connect to the router/modem. Logics strongly recommend that no 3rd party services share a business Broadband line. Should a 3rd party service because a Broadband fault, the customer could be charged for the work involved in resolving the Broadband fault. The customer is also responsible for the hosting of their own website and email addresses associated with that domain name. The customer needs to be aware that if they do not own their own domain for e-mail. e.g. email@example.com that their e-mail address will change. If the customer uses an e-mail address supplied by their current broadband provider this WILL change to a Logics e-mail address. The charge for onsite installation will be £60 for the first hour and £40 per hour thereafter. £65 installation charge for 30 days roll over contracts.Additional Info 29.99 39.99 89.99 179 Bonding Service Yes No ADSL package to be ordered Need to send new configured router(for liverpool support people already send the router) Authorization Please ensure that all relevant sections of the Order Form are completed. I have read and agree that all information is correct and as required. SignedDate Contract Term:30 Days12 Months24 Months36 MonthsDeclaration – I confirm that this agreement commits the customer to receive the service for the Minimum Period identified above. I confirm my understanding that the Minimum Period will automatically extend unless terminated in accordance with Clause 4.1 and 9.2 of enclosed Terms and Conditions and that the Customer may be liable for certain payments in the event of termination before the end of the Minimum Period. I confirm that I fully understand the Terms and Conditions enclosed. I confirm that I am authorized to bind the Customer to the terms of this agreement. SignedDate Print NamePositionSignedDate * We accept the terms and conditions For and On Behalf Of Logics Technologies Ltd This iframe contains the logic required to handle AJAX powered Gravity Forms.