Commercial Broadband Service Initiation Form.
Viewing this Activation Form is a confirmation that Internet has been activated and you have connectivity the World Wide Web. Please take a moment and fill out as much as you can of this form to help us insure a proper setup of your new account. (Fields with * are required)

   Section (1) On-Site Person Contact Information

* Company Name:
* Installation Address:
* City, State & Zip code:
* First & Last Name:
* Title:

* Primary Phone:

  Ext.
Alt. Phone:

* e-Mail:

Local Contact Notes:


   Section (2) Account Payable - Billing Information

* Billing Info.:

Billing Address:
City, State & Zip code:
First & Last Name:

Primary Phone:

  Ext.
Alt. Phone:

e-Mail:

Billing Notes:


* Service Start Date:

* Recurring Monthly $:

* Prorated 1st Month $:

* Monthly Billing Method:

Credit Card: cvv: Exp:
Name on Card:    Card Zip Code:

Take $25 Off Activation when you select "Credit Card Auto Pay. Note: a printable invoice will be 
emailed monthly regardless of billing method selected above.
  

   Section (3) Equipment, Install & System Configuration

Invoice Number:
Installed By:
Antenna: SN:
SNR Reading: DB Amplified:
Visible Access Point:
Cable Run: in Feet
Wall Plate:
Wireless Bridge: SN:
Router Installed: SN:
Assigned IPs:
General Notes:

        

For more details please call us at 703-266-1000 or fill-out a site survey form click here