Home Internet Application Form – Misawa –

User Information

Last Name *

First Name*

Middle Name

Date of Birth* YYYYMMDD

Gender*

MaleFemale

TEL (Cell) *

E-mail *

Mail Box# *

Squadron/Office name *

Duty phone *

DEROS/PRD * YYYYMM

Location of Internet

Zip code Leave blank if unknown

Address Leave blank if unknown

House number*

Real estate agency*
-----E-TRUST(I-RINK)Yamamoto ShojiSato KomutenTaiko's OfficeSanrokuO.T.KKeageother

Real Estate agency name if it is not listed above.

Moving from on-base to off-base

Yes	Check yes if you are relocating from on-base housing to off-base housing.

Plans

Monthly plan

Hero L PlanHero S Plan

Hero L Plan - One year contract
Monthly Fee -First Year-	¥7,700/month
Monthly Fee -2nd Year~-	¥6,600/month
Installation Fee	¥0 FREE -Special offer for Hero L Plan-
Sign-up Fee	¥3,300
Cancellation Fee	¥13,200 if cancelled within a year

Hero S Plan - Month-to-Month contract
Monthly Fee	¥7,700/month
Installation Fee	¥6,600 ~ ¥17,600
Sign-up Fee	¥3,300
Cancellation Fee	¥0

Installation fee

Installation Fee will be charged if you select Hero S Plan.
We will notify you of the total amount for installation fee when the installation schedule is confirmed.

Rental Pocket Wi-Fi

Yes	Check if you would like to use pocket Wi-Fi until Installation date.

*You will be asked to visit HeroNet office to pick up the pocket Wi-Fi. The contract will start from the date you pick up the pocket Wi-Fi.

Rental VPN router

Yes	Check if you would like to add VPN router(¥1,500/month) to monthly plan.

Payment method

G.I Bill Pay ServiceCredit card

• G.I. Bill Pay Service
• Credit cards：Visa／Master Card／NICOS／JCB

Uploads

Please upload your ID(Driver's license or Passport).
*You can take picture or scan the documents

Upload ID*	U.S. Drivers Lisence or Passport

Inquiry

I read the HeroNet Internet Service Policy and agree to the terms provided above.

I confirm that the information given in this form is true, complete and accurate.

Yes, I would like to apply for HeroNet Internet service.