First Name:*           Middle:

Last Name:*   

Service Address1:*     

Service Address2:       

City: *                    State:*  

Zip Code:*      

Service Area Code:*     Service Phone Number:* Enter numbers only, no dashes ("-").

Company Name:    

E-Mail Address: 

What is your current level of Internet Connectivity: *
Select One Dialup ISDN DSL Fractional T1 T1 T3 Other/Not Sure Not connected

How many locations need Internet Connectivity: *  Select One One 2-5 5-9 10+

How many computer users are on your LAN:  *   Select One 1-10 11-50 51-100 101+

Select the connectivity speed(s) you would like quoted: *  
64 Kbs     128Kbs    384Kbs   512Kbs   
768Kbs    T1            T3

Select the contract term(s) you would like quoted: *           
1 Year  2 Year   3 Year  5 Year

Are you considering implementing a Firewall or Virtual Private Network (VPN)?:  Select One Yes No Have One Don't Know

What is your timeframe for implementing/changing Internet Access
to your LAN?:  Select One 45 Days or less 90 Days or less 120 Days or less Don't Know

What is your monthly budget for Internet connectivity?
Select One Under $100 $100 - $1,000 $1,000 - $2,500 $2,500 - $5,000 Over $5,000 Not sure