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To order DSL service at your home or business, please complete this form. Fields in bold are required for processing.

Once submitted, your order will be sent to our sales department to run a qualification check on your address. You will be contacted regarding your qualification results, package availablility, and billing information.

Enter the address where DSL service will be installed:
Name: Contact:
Address: Apt.:
City: State: Zip:
E-Mail:
Enter your phone number with area code below. This number must be a land-line phone that rings at the location specified above and will have DSL service added to it. It should be a fax or stand-alone line, not part of any phone system.
Phone: - -
If you have an alternate phone number that you should be reached at during the day, please enter it below. If not, you will be contacted at the number above.
Contact Phone: - -
To expedite the ADSL ordering process, please answer the following questions about the land-line phone that you specified.
Does this number have local phone service from Ameritech? Yes No
Are any special services present on the phone number
provided above, such as Centrex or hunt group?		 Yes No
How many phone lines do you currently have installed at this
location?
Is there a phone jack installed where your computer is located? Yes No
What is the manufacturer of your computer?
(Apple, Compaq, Dell, etc.)
How much RAM (memory) does your computer have?
Is your computer equipped with a network card? Yes No
Is this network card in use? Yes No
What operating system does your computer run? Windows 95/98
Windows NT/2000
Windows XP
MacOS
Unix (BSD or GNU/Linux)
DSL Package being ordered: Fireline 1500
Fireline 3000
Fireline 6000
Fireline 6000 Pro
Fireline SDSL