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Order details form
Please fill out the below information to help us process your inquiry and order
Your name
*
SSN
Phone number
Email
Preferred contact method
Please select at least one option.
Email
Phone
In-person meeting
Registered account name
*
How can we help?
*
How did you hear about us?
Select
Online Search
Social Media
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Referral
If referred, please let us know who to thank!
Who referred you?
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Additional services needed
Please select at least one option.
Router Setup
Wi-Fi Access Points
Network Security
Technical Support
Fiber Internet / Dedicated
Shared Fiber / Coax / Broadband / Best Effort
Access control / door codes / key cards
Low voltage / wiring
Camera systems
POS / Credit Card Processing
Business TV (Public / Private / Commercial)
Business name
*
Email address
*
Requested installation date (please give 30-90 days lead time from placing order to account for possible construction to get to your site)
Requested account PIN (4 digits)
*
Secret question (your choice)
*
Please select at least one option.
Favorite restaurant (Ex: Taro's Sacramento)
Favorite actor (Ex: Adam Sandler)
Favorite childhood hero (Ex: Underdog)
Favorite singer (Ex: Dave Matthews)
Ex: What’s your favorite band?
Business address
*
Current internet provider
*
Service type requested
Please select at least one option.
Standard Internet
High-Speed Internet
Dedicated Internet
Wi-Fi Setup
Network Security Services
Cloud Services
Email management
Desired internet speed
Select
Up to 300 Mbps
301-500 Mbps
501-1000 Mbps
1001-2000 Mbps
Installation / IT point of contact name
*
Additional comments or requirements
Billing address if different
Preferred internet package
*
Dedicated Fiber / EDI / Guaranteed
COAX / Broadband / Best Effort
Shared Fiber
Dedicated Fiber / EDI / Guaranteed
Advanced system needs
Technical support required
Please select at least one option.
24/7 support
On-site support
Remote support
Email support
Installation only
Network setup required
Select
Wired
Wireless
Both
Additional equipment needed
Please select at least one option.
Router
Modem
Switch
Firewall
Network cables
Access points
Preferred payment method
Select
Credit Card / Debit Card
ACH / Autopay
Installation site
Special requests or considerations
Service level agreement requirements
Please select at least one option.
24/7 Support
Guaranteed Uptime
Performance Monitoring
Data Backup
Internet usage type
Please select at least one option.
General Browsing
Streaming
Gaming
Cloud Services
VoIP
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