Residential Service Request

Name: *		Email Address: *
Address: *		City, State, Zip: *
Phone Number: *
How You Heard About Us:		Comments:
Internet Service Plan:	Select One Basic - Symmetric 3 Mbps - $26.50 Value - Symmetric 20 Mbps - $48.50 Performance - Symmetric 50 Mbps - $74.50 Lightning - Symmetric 100 Mbps - $94.50 Gigabit - Symmetric 1,000 Mbps - $245.00	Voice service plan:	Select One Basic Phone - $17.50 Unlimited Phone - $28.50
Promotions and Packages:	Select One The Works - Internet 30 Mbps, Unlimited Phone - $77.00 Cable Buster - Internet 10 Mbps, Unlimited Phone - $63.00 Enhanced Basic - Internet 4 Mbps, Unlimited Phone - $55.00