Customer Name

Administrator's Name

*
(name of person completing this form)

Email Address

Company Name

Address

Date

2/4/2012

Order/PO Number(s)

Country Code - Phone Number

Purchased Service Plan

Platinum (SW/HW)Gold (SW only)Bronze (HW only)

	Site Name	Device Description	Serial #	Freq. (if applicable)	Site Name	Device Description	Serial #	Freq. (if applicable)
Link 1
Link 2
Link 3
Link 4
Link 5

Comments:

check these boxes to indicate you have read and agree to terms for the Maintenance Plan Activation

All information is accurate and true to my knowledge.
Submission of this form formally activates the GigaBeam Maintenance Plan. All products covered under the plan must be noted on this form.