Request For Immediate Broadband Service Information
Name of Business
Your First Name
Your Last Name
Phone Number to Contact You
ext.
Your Title
Your Address
City
State
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AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Your E-Mail Address
Phone number at site for this service?
Service of greatest interest
Choose From List
Full T1
Fractional T1
T1 with VPN
VPN Only
Private Line
Multiple T1's
Business DSL
Full T3
Partial T3
Frame Relay
DS3
OC-3
Other
Computers at site of connection?
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Less than 5
5 to 20
20 to 100
More than 100
Where will this connection be?
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Office
Office in Home
Residential use
How many locations are part of this request?
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1 Location
2 to 5 Locations
5 to 10 Locations
10 to 20 Locations
20 to 50 Locations
50 to 100 Locations
More Than 100 Locations
Do you have an existing contract for broadband services?
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No
Yes
If so, when does your current contract expire?
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October 2003
November 2003
December 2003
January 2004
February 2004
In six months or more
No contract in place
Comments: