Internet Request Form
Please fill out the form below and we will get in contact with you as soon as possible.
Name:
Company:
Mailing Address:
City:
State:
Zip Code:
Physical Address same as Mailing Address
Physical Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
How did you
hear about us?
Which service are you interested in?
Wireless Internet
Up to 512 Kbps $50/month
Up to 768 Kbps $75/month
Up to 1000 Kbps $100/month
DSL
Up to 768/384 Kbps $20/month
Up to 1.5/384 Mbps $30/month
Up to 3.0/512 Mbps $40/month
Up to 6.0/768 Mbps $60/month
Dialup
Up to 56 Kbps $119.88/year ($9.99/month)
Notes or comments:
