CONNECT SI BROADBAND
REQUEST FORM
Name
____________________________________________________
Business Name
____________________________________________________
(if
applicable)
Physical
Address
____________________________________________________
(for service)
____________________________________________________
Mailing
Address
____________________________________________________
(if different
than above)
____________________________________________________
Phone Number
____________________________ Email
______________________________________
Do you
already have Internet service at your physical address?
If so, what kind of service do you have at the present?
□
I don’t have any Internet service at this time
□
Dial-up
□
Cable Modem
□
Fixed Wireless
□
Satellite
□
Other Internet
Is this
service for your home, or for your business?
□
Home
□
Business
Do you have
any other special needs, or are there other Internet-related services in which
you are interested?
□
I am interested in Web site hosting
□
I am interested in eCommerce (selling my goods or services
online)
□
I use my connection to send or receive large files (large
graphics, blueprints, professional audio or video)
□
I an interested in VOIP (Voice-Over-IP, using my Internet
connection to supplement or replace traditional phone service)
□
I am interested in server co-location or dedicated hosting
Are there any other special services you may need, or any other details relevant
to your request? If so, please
specify
__________________________________________________________________________________
Completing this form is not a commitment on your part to buy service, nor is it
a commitment of service by any member of Connect SI.
We will send your request to all the Internet service providers
affiliated with Connect SI, and any providers who believe they can provide
service to you will contact you.
Terms of agreement: I understand and
agree that the information I provide will be used by the Internet Service
Provider (ISP) members of Connect SI for purposes of evaluating their ability to
meet my Internet connectivity requirements.
My address information may be used to develop maps to help Connect SI to
understand where gaps in Internet availability may exist.
I grant approval to the member ISPs of Connect SI to contact me, using
the information provided, for the purpose of attempting to provide to me
Internet service. Connect SI and its
member ISPs will use this information only for these purposes and no others.
□
I agree to the above terms and conditions
Mail the above form to:
Susan Odum