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Property Owner Information

Name*

First Last

Email*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

As the Owner or Duly Authorized Manager of the property located at (enter street address below) I (we) hereby authorize Champlain Broadband LLC, DBA Burlington Telecom, to install communication cable and equipment and any internal wiring necessary to provide voice, internet and cable services to the property. This form provides permission for all units in a multi-dwelling. I also agree to the installation for additional properties I own listed below.

Tenant Information

Name*

First Last

Phone*

Address*

Street Address

Owner Occupancy?*

Yes

Housing Type*

Single Family

Duplex

Condo

Multi-Unit

Special Instructions

Your Digital Signature*

ACCEPTANCE OF TERMS AND CONDITIONS The typed name above is considered an official signature. By providing your signature above, you agree to all terms and conditions of this Agreement. For the purpose of this agreement it is understood that by signing this LETTER OF AUTHORIZATION in no way obligates the property owner to accept communication service from Burlington Telecom. It is further understood that no such inside wiring or installation will take place until a service order is initiated by the property owner or tenant thereof. By signing this agreement, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. This is consent to be legally bound by this Agreement’s terms and conditions.

Need More?

Yes

Additional Properties

Address

Street Address

Housing Type

Single Family

Duplex

Condo

Multi-Unit

Address

Street Address

Housing Type

Single Family

Duplex

Condo

Multi-Unit

Address

Street Address

Housing Type

Single Family

Duplex

Condo

Multi-Unit

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Landlord Letter of Permission

Property Owner Information

Tenant Information

Additional Properties

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