Name *

First Name

Last Name

Service Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Number *

(###)

###

####

Alternate Contact Name *

First Name

Last Name

Alternate Contact Number *

(###)

###

####

Requested Start of Service Date *

MM

DD

YYYY

Internet Speed *

None

50 mbps $65/month

100 mbps $75/month

200 mbps $95/month

500 mbps $125/month

1 GIG $175/month

TV Options *

None

Local Basic $54.95

Basic $109.95

Expanded $120.95

Phone Options

Local Line $29.25 (Includes Call Waiting, Caller ID, Call Forwarding, Automatic Recall)

Long Distance (We will verify the carrier and plan with you after receiving the application.)

Voicemail $4.00

Caller ID Name $1.50

Additional Services - Check a box below if you you have interest in the services below.

Outdoor Mesh - WiFi connections to outbuildings.

Camera System - Custom designed surveillance systems with smart phone control.

Broadband Privacy Policy Agreement (Click the link at the bottom of the page to view the Policy) *

I Agree to the Broadband Privacy Policy

Date *

MM

DD

YYYY