Residential Services Inquiry Form For Internet, TV, and Telephone Note: YOU MUST BE IN A QUALIFYING AREA Please indicate what services you are interested in, we sell the following : Comcast/Xfinity Cable TV, High Speed Internet and Telephone DirecTV / HughesNet / CenturyLink / Ziply Fiber / Dish Network / PogoZone First & Last Name     Physical Street Address (NO PO BOX) City / State / ZIP     Contact E-mail Address Contact Phone # ( ) - - (ie. 123-456-7890) Preferred Contact Method Select Phone Email Current Service Provider Select Just Moving In Xfinity/Comcast CenturyLink Charter (Spectrum) Time Warner (Spectrum) Cox AT&T Ziply Fiber Cable One Viasat Dish Network DirecTV Verizon Windstream HughesNet Wow Mediacom ADT Other/None *Put in notes Desired Provider Select CenturyLink Comcast/Xfinity DirectTV Dish Network Ziply Fiber (DSL) HughesNet PogoZone Viasat Other/Not Sure Desired Services Select Internet TV Phone Internet + TV Internet + Phone TV + Phone Internet + TV + Phone Other/Not Sure     Notes: REQUIRED CAPTCHA MATH QUESTION Captcha Add (35+55)