HIGH BANDWIDTH INTERNET ACCESS 

 REQUEST FORM

Company Name:
* Service Location: Street Address:
* Service Address: City:
* Service Address: State:
* Servie Address: Zip Code:
Service Address: Phone Number:
* Contact Person: Name:
* Contact person: Email Address:
* Contact person: Phone Number:
Current Internet Provider:
Current Internet Connection (Speed):	T-1 or Less T-1 (1.5Mbps) 1.5 to 45 Mbps Greater than 45Mbps
* Requested Internet Speed for this Quote - (in Mbps):	1.5 - 3Mbps 3 - 4.5Mbps 4.5 - 10Mbps 10 - 25Mbps 25 - 45Mbps 45 - 100Mbps 100 - 1000Mbps (GIGE)
Local Loop Requested:	Multiple T-1:|:s DS3 OC3 Ethernet Handoff (100Mbps up to GIGE) Wireless
Do you need this circuit provided with a router? :	YES (may increase cost) No (can lower cost and increase # of Carriers who will quote).
How soon do you need this Service installed?:	ASAP 1 - 3 months 3 - 6 months 6+ months
Comments & Additional Information:

HIGH BANDWIDTH INTERNET ACCESS 

 REQUEST FORM