High-Speed & Broadband Access Order Form

Service Information

Service *

  GAS 6/1 ADSL
  FTTN 10/1 xDSL
  FTTN 16/1 VDSL
  FTTN 25/10 VDSL
  FTTN 50/10 VDSL
  15MBit Cable
  30MBit Cable
  100MBit Cable

Dry-Loop

Service Phone Number

Activation Date *

Tech-Visit Time

  Morning
  Mid-Day
  Afternoon
  Evening

Add-Ons

  Modem (required)
  802.11N Wireless Router
  Managed/IPv6/VPN Router

Account Information

Name *

E-Mail Address *

Contact Phone Number *

Address *

Billing Interval

  Monthly
  Quarterly
  Biannually
  Annually

Comments & Special Instructions