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First Name *

Last Name *

Title

Date of Birth

Primary Phone Number *

Secondary Phone Number

Work Phone

Email (All correspondence including your service agreement, installation scheduler, and billing information will be sent to this email address.) *

Spouse's Full Name (if applicable)

Spouse's Email *

Street Name

City *

State *

Zip *

Your Fiberhood

Is your billing address different from your service address? *

Yes, they are different.

No, they are not.

Billing Street Address *

Billing City *

Billing State *

Billing Zip *

Are you currently an existing customer? *

Yes I'm a current Customer

No, I am not a current customer

Do you rent or own the property where you are looking for service? *

Rent

Own

Landlord Name *

Landlord Email

Landlord Phone Number *

Internet Details

*Internet speeds will reflect best available speed "up to". Customers will receive our fastest available speed to your home.

Package *

Package

*Speeds not guaranteed in all areas.

Managed Wi-Fi & Router - $6.95/month

Telephone Offerings

ECTC Phone Service *

I wish to add land line service.

No Thank You

TV Offerings

(Must be taken with High Speed Internet or Landline Phone Service)

Package

Interested in High Definition for $9.95 per month? *

Yes, I would like High Definition Programming

No Thank You

Set Top Boxes are $4.95/month/box
How many set-top boxes are needed?

Bill Payment & Additional Options

E-Mail Account information - if Requested
Username (4-20 characters)

Password ( 8 char. Min.)
Your Password must contain at least 8 characters
Select a combination of letters or numbers that ONLY YOU can remember.

Bill Pay Options *

eBill

PaperBill

Plow Charges:
$200 charge up to 300ft
$350 Up to 750 feet
$700 Over 750 feet up to 1,500 feet
Any drops over 1,500 feet will be bid. *

Yes, I have read the above Plow Charges and am aware that I will be responsible for any charges upon install.

How did you hear about us? *

To assist our construction crew, please list any fences or buried facilities (geothermal lines, sprinkler system, etc.) on your property that would not be found during a Gopher One Call locate.

Any comments or additional information that we should be aware of?

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