FTTH Service Change Request

FTTH SERVICE CHANGE REQUEST

Service Provider:     Client Name:

Whereas

WHEREAS, Service Provider is the licensed provider of fiber-to-the-home network services serving the Service Address identified above and maintains account and provisioning records for the Client; and

WHEREAS, Client requests modifications to the existing FTTH services and associated customer premises equipment as set forth in this Service Change Request; and

WHEREAS, the parties desire to document the scope, fees, timing and terms under which Service Provider will implement the requested change.

Scope of Work

The Service Provider shall perform the following work to implement the requested FTTH service changes at the Service Address. Tasks may include provisioning bandwidth changes, reconfiguring ONT/ONT replacement, scheduling a field technician visit, and updating billing records.

Requested Change

Select type(s) of change requested:

Upgrade speed Downgrade speed Add service (IP, IPTV, VoIP) Remove service

Desired Implementation Date:

Equipment and Access

Yes No

Payment Terms

By signing this Request, Client authorizes Service Provider to charge any applicable non-recurring charges, monthly recurring charges, and equipment fees described below.

Late Payment Fee:    Grace Period (days):

Term and Termination

Implementation Start Date:

Anticipated End Date (if applicable):

Confidentiality

Each party acknowledges that in connection with the performance of the change described herein it may receive or have access to proprietary or confidential information of the other party. Each party agrees to hold such information in confidence and not to use or disclose it except as necessary to perform obligations under this Request or as required by law. Confidential information does not include information that is or becomes publicly known through no fault of the receiving party or that the receiving party lawfully obtains from a third party without restriction.

Governing Law

This Service Change Request and any disputes arising out of or relating to it shall be governed by and construed in accordance with the laws of the state of without regard to conflict of law principles.

Entire Agreement

This document, together with any service-specific schedules or rate attachments signed by the parties, constitutes the entire agreement between Service Provider and Client with respect to the requested FTTH change and supersedes all prior proposals, understandings and representations, whether oral or written. Any amendment or waiver must be in writing and signed by authorized representatives of both parties.

Authorization and Certification

By signing below, Client certifies that it is authorized to request the changes set forth herein, that the information provided is accurate, and that Client agrees to the fees, scheduling and terms described in this Request. Service Provider certifies that it will perform the work in a commercially reasonable manner consistent with industry standards.

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