Futiva Fiber Sign-Up form

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

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 *

Would you like our Managed Wi-fi service, which includes a carrier-grade router for $9.99/month? *

Yes

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

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) *

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