Wufoo

Service Request Form

Please fill out this request for services. Incomplete forms are discarded.

Name First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone ### - ### - ####
Email
Web Site
Service Requested *
Basic Dialup $10 a month Pro Dialup $14.95 per month (w/filtering) Basic Hosting $10 a month Deluxe Hosting $20 per month Content Filtering $5 a month wDSL Basic - $50 a month / $500 Yr wDSL Pro - $75 a month / $750 Yr wDSL Platinum - $100 a month / $1000 Yr VOIPit In Basic $10 a month VOIPiT Out Basic $10 a month VOIPiT Free net2net - Free IPTV - Free* with services Media Center - $9.95 per month

What type of service do you want ?
Notes

Please give us any details

How are your Internet needs and demands?
	Strongly Disagree	Disagree	Agree	Strongly Agree
I live online, need VPN, VOIP and IPTV. Fastest thing you got !	1	2	3	4
I use the net for homework and or online courses and business.	1	2	3	4
I just use the internet to keep in touch with my friends across the world or meet new ones.	1	2	3	4
I keep my PC protected and up to date! My antivirus , malware cleaners and trjoan protection are up to date and working.	1	2	3	4
I have never had a data failure, ever.	1	2	3	4

Broadband Needs
	Strongly Disagree	Disagree	Agree	Strongly Agree
Need cheap data connection 256-384 min ( 2-3 megabit max)	1	2	3	4
Need VOIP and feautes to reduce call costs.	1	2	3	4
Need IPTV for online media, movies, TV programs, and more.	1	2	3	4