DSL Order Form
Please enter the following information
(* required fields)
Contact Name:
*
Contact Phone:
*
Email Address:
Company:
Service Address:
*
City:
*
Province:
*
Postal Code:
*
Phone Line for DSL:
*
Fax:
Customer Account#:
Installation Date:
Installation Time:
AM
PM
Either
Type of Service:
DSL-Home (1.5Mbps)
DSL-HomeOffice (1.5Mbps)
DSL-Business (2.5 Mbps)
DSL-BusinessMax (4 Mbps)
ADSL Modem:
Purchase Modem
Rent Modem
Have Own Modem (must be approved)
Special Requirements: