VeroLAN Support - Commercial BroadBand Activation Form

Residential HIGH-SPEED Internet Access Service Request Form
                                                                               GO TO Commercial 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 residential or business location.

   Section (1) - Contact Information

* First & Last Name:

* e-Mail:

* Installation Address:

* City, State & Zip:

* Primary Phone:
Ext.

Mobile:

Alternate Phone:

   Section (2) - Service Information

* Requested Service Start Date:

* Preferred Service Plan $:

* Number of Computers:

* Operating Systems:

* Current ISP:

* Current Speed Delivered:

* Combined Satellite TV:

Reason for switching:

* How did you know about us?:

* Dwelling Type:

General Notes: