Wireless Service Pre-Qualification Info

The following information form is necessary for us to determine if your location qualifies for Wireless Internet Service. All secure information will be taken either in person or over the phone to ensure your privacy after we have determined that you qualify.

First Name: Last Name: Service Address: Billing Address: City: State: Zipcode: Email Address: Phone Number: Credit Card Type: (Mastercard, Visa, Discover, American Express) Plan Requested: (Clear Value, Clear Premium, Clear Business) Length of Contract: (1 or 2 yrs.) Have you read and Agree with the Terms of Service: (Yes or No) Did someone refer you, if so who: Will you need Networking Assistance: (Yes or No) Business Name: (if personal enter N/A) If you have any questions or comments please note them here:

We will call to tell you the status of your qualification, ask for your secure info, and let you know how to get the wireless modem just as soon as possible. To finalize your order we will need an account name, password, credit card number,cc expiration date, drivers license number, and approval of the contract.
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We will be in contact with you soon... We look forward to working with you!

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This information will be considered private and confidential.

Web page created by Electronic Assistance Corporation. Last updated 10-11-05.