VeroLAN Support - Commercial BroadBand Activation Form

Commercial HIGH-SPEED Internet Access Service Request Form
                                                          GO TO Residential Service Request Form

Please take a moment and fill out as much as you can of this form to help insure a proper service initiation process. Filling out this form will not result in any charges or fee, this is simply data gathering phase enabling to create an error free record and/or to schedule a free site survey if deemed necessary due to doubts in service availability in your business location.
(Fields with * are required)

   Section (1) - Contact Information

* First & Last Name:

* Company Name:

* e-Mail:

* Installation Address:

* City, State & Zip:

* Primary Phone:
Ext.

Mobile:

Alternate Phone:

   Section (2) - Service Information

* Desired Service Start Date:

* Preferred Service Plan $:

* Number of Computers:

* Do you have a Network?:

* Operating Systems:

* Current ISP:

* Current Speed Delivered:

* How did you know about us?:

* Building Type:

General Notes: