AGREEMENT for WIRELESS ADSL SERVICE Last name: First name: Address: C.A.P.: Middle name: Gender: M F Base Americana CAMP DARBY - Via Vecchia Livornese 56018 Place of birth: Driver’s License: Località: TIRRENIA State: PISA Date of birth: Number: Issued by: Phone number: Province: Issue Date : Mobile: E-mail: Codice fiscale: Bldg: Room: Agreement: The ADSL WIRNET agreement becomes effective as of the date Wirnet receives this form properly filled out and signed, the copy of the payment receipt and copies of driver’s license and codice fiscale. The agreement is effective for a minimum period of 2 months and is automatically renewable for successive terms of equal lenghts unless you request cancellation. The cost for activation is 30,00 Euro and the cost for 2 months of service is 60,00 Euro. Upon signing up you MUST pay the activation fee and the service fee according to the bimester (Jan-Feb, Mar-Apr, May-Jun, Jul-Aug, Sep-Oct, Nov-Dec). The service fee for additional bimesters are due NLT the 15th of the first bimestral month ( 15 Jan, 15 Mar, 15 May, 15 Jul, 15 Sep, 15 Nov). Should you choose to terminate your agreement prior to the end of its term you will not be entitled to a refund. Payments can be done at the Community Bank using the following Recipient data: Name: TECNOCOM SRL IBAN: IT55 L076 0114 0000 0100 1435 872 BIC: BPPIITRRXXX If your payment is late the service will be suspended the 1st day of the second bimestral month (1 Feb, 1 Apr, 1 Jun, 1 Aug, 1 Oct, 1 Dec) and you will be responsible for paying a re-activation fee. Data Protection Act: Consent to use your personal data for this Internet service. I authorize I do not authorize PLEASE ATTACH COPY OF YOUR DRIVING LICENSE AND COPY OF YOUR CODICE FISCALE Date Signature Tecnocom Srl - Sede legale Via Leonardo da Vinci, 10/5 – 56033 Capannoli (PI) - Sede operativa Via M. Buonarroti, 22 – 56033 Capannoli (PI) Tel. 0587 606148 Cell. 335 6188595 Fax 0587 606964 e-mail [email protected] –C.F. e P. IVA 01228630503