Residential Sign Up Form

Account Name *
Street Address *
Billing Address (optional)
City/Town
State
Zip Code
Contact Phone Number *
Alternate Phone Number
Please select an internet speed plan *	— Select from list — Fiber 100 ($75) Fiber 300 ($85) Fiber 500 ($105)
Would you like our video services?	— Select from list — PureHD TV ($70) DirecTV-Entertainment ($84.99) DirecTV-Choice ($99.99) DirecTV-Ultimate ($129.99) DirecTV-Premier ($174.99)
Would you like our phone services?	— Select from list — No thanks Yes add phone service ($29.99) Yes add unlisted phone service (additional $7 per month)
Do you rent or own the property?	— Select from list — Own Rent
Please select a router	— Select from list — Blast Max Router ($14.99) Blast Mini Router ($11.99) No thanks
Would you like Wi-Fi mesh unit(s)?	— Select from list — 1 ($4.99) 2 ($9.98) None
Contact’s First Name *
Contact’s Last Name *
Contact E-Mail Address