Request for Immediate T1, Private Line or MPLS Information
Name of Business
Your First Name
Your Last Name
Phone Number to Contact You
ext.
Your Title
Your Address
City
State
--
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
T1
Fractional T1
T1 with Integrated Voice & Data
T1 with VPN
T1 & Cost-Effective Phone Services
Business VOIP Services
VPN Only
Point-To-Point
Private Line
Multiple T1's
Business DSL
T3
Partial T3
MPLS
OC-3
Other (Please explain below)
Type of location?
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Office
Home Office
Residence
Computers at site of connection?
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Less than 5
5 to 20
20 to 100
More than 100
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
Timing of your buying decision?
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Within two weeks
ASAP!! This is an emergency!
Within one month
Within three months
Within six months
Not yet decided
Current Internet connection?
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DSL
Dial-Up
Full T1
Fractional T1
ISDN
Satellite
Frame Relay
Private Line
MPLS
VPN
Other
Do you have an existing contract for broadband?
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No
Yes, expiring in less than one month.
Yes, expiring in one to three months.
Yes, expiring four to six months.
Yes, expiring in seven months or later.
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