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)