Site Survey
First Name:
Last Name:
Physical Address:
City:
Phone:
E-mail:
Directions to Site:
How Many Computers:
-
1
2
3
4
5+
Need Appointment:
Yes
No
Network:
Yes
No
Account Type:
Business
Residential
Package Preferred:
Select a Package
Basic (384-512K)
Gold (768K-1M)
Platinum (1.5-2M)
How did you hear about us?:
Comments:
