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Wireless Sign Up Form
Customer Name:
Road Name:
5 digit green sign, also known as 911 service location in most municipalities (enter zeros if none/unknown):
What is the billing address?:
GPS Coordinates?
Phone number(s) at which you can be reached?:
What is the best time to call?:
Current e-mail address, if any:
Bungalow
Two Story
Mobile Home
Log House
Commercial Building
Other
How many stories is the building to be installed?:
Shingled
Shale
Shake
Steel
Tin
Other
Is the roof Shingled, Shale, Shake, Steel, Tin?:
How steep is the roof? Flat, a little steep, very steep, x degrees?:
One
Two
Three
Four or more
How many devices are there? (For more than one a router is needed.)
No
Yes
Will be renting one
Is there currently a router?:
Internet 100
Internet 50
Internet 25
Please select the desired plan:
How did you hear about us?:
Is there a current usable antenna mount, are there obstacles like trees around the area?
No
Yes
Do you own the property?
Additional Notes