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DSL Internet Qualification Form
Please fill out the following form regarding your DSL Internet needs
and a member of our sales team will promptly respond.

Order Information
First name:
Last name:
Company:
Phone service is:
Address (as it appears on phone bill):
City, State
Zip
E-mail:
Contact Phone:	() -
Phone line for DSL line:	() -
Term:
Who do your current phone bills come from?:
Current Internet Access:
Comments: (Use this space to describe how you use the Internet and to insert any special instructions or questions)