First Name * Last Name * Your Fiberhood Address * City * State * Zip * Do you rent or own the property? * Own Rent (Landlord Approval Required) Landlord/Property Owner's name * Landlord/Property Owner's phone number * Is your billing address different than your service address? Yes No Billing Street Address Billing City Billing State Billing Zip Email ( All correspondence including your service agreement, installation scheduler, and billing information will be sent to this email address. ) * Home Phone Cell Phone * What is the best contact telephone number to reach you on? * Home Phone Cell Phone Please select your Service Package * $59.99 - 50/5 $69.99 - 250/50 $79.99 - 500/100 $99.99 - 1 GIG/250 I need MORE speed. Contact me about faster plans. Would you like our Managed Wi-fi service, which includes a carrier-grade router for $9.99/month? * Yes No Are you interested in VoIP Home Telephone Service? Local Phone $15.00/mo per line Includes Unlimited Local and LD Calling, Voicemail & Calling Features, Plus keep your same phone number. *Requires purchase of analog telephone adapter for $44.99+tax. This item will be shipped to the customer. Customer is responsible for activation and installation of device. Do you want to keep your current telephone number? * Yes No Current Phone Provider? * Frontier Mediacom Clearwave Verizon OtherOther Current telephone number * Current telephone number #2 Please write in anything that our construction crews need to be aware of in your yard. (Dog Fence, Sprinkler System, etc) Questions or Comments Once we receive this completed form a customer service representative will contact you to collect the activation fee. At this time we will require your Social Security Number to perform a credit check. Please provide the best time to contact you. What is the best time to contact you? (Monday - Friday 7:30AM - 5:00PM) * Captcha
