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 are some directions to the site? (From nearest gas station, and the name of that station):

What is the billing address?:

What is the closest city/town?

What are the nearest cross roads?:

Phone number(s) at which you can be reached?:

What is the best time to call?:

Current e-mail address, if any:

How many stories is the building to be installed?:

Is there a basement, if so is it finished?

Is the roof Shingled, Shale, Shake, Steel, Tin?:

How steep is the roof? Would spiderman have problems, or can an old man do it even if covered with snow and ice?:

What operating system is most used in the building?:

How many devices are there? (For more than one a router is needed.)

Is there currently a router?:

Please select the desired plan:

Do you want to sign up or just want more information?

How did you hear about us?:

Is there a current usable antenna mount, are there obstacles like trees around the area?

Are you available for an install on short notice?:

Do you need a tower?

Do you own the property?

10 IXL Crescent
East Selkirk MB
R0E 0M0

204-481-CROW (2769)