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Last Name

First Name

Address

City

State/Province

All information is kept strictly confidential.  We do not sell our mailing lists and do not send unsolicited email.

Zip or Postal Code

Country

Daytime Telephone

Evening Telephone

Fax Telephone

E-mail

 

WIRELESS SERVICE

 

I don't have a cell phone, or wireless card for my laptop,
and I don't plan on getting one (PLEASE SKIP TO NEXT SECTION)

I like my carrier and don't want to switch even if I would save money

I will consider switching carriers

Please note:  Carriers may offer incentives to sign a new contract, so changing may save you significant money, especially on upgrades or new equipment.

CURRENT PROVIDER

My monthly bill is approximately

Minutes on plan

Months left on contract

Number of phones on plan

I like my cell phone handset

I am only interested in updating to a free or low-cost handset

I am interested in updating my handset

I am interested in a wireless card for my laptop

 

LOCAL/LONG DISTANCE

 

I don't have a land line and I am not interested in having one (PLEASE SKIP TO NEXT SECTION)

CURRENT PROVIDER

Area

Prefix

Number

Primary phone number

(

)

-

My monthly bill is approximately:

Bundled with:

Internet

TV

Both

Total bill

Do you make International calls?

Yes

Which countries?

No

Do you make in-state long distance calls?

Yes

No

Are you interested in unlimited calling?

Yes

No

 

HIGH SPEED INTERNET

 

I don't high speed Internet and I don't want it.  (PLEASE SKIP TO NEXT SECTION)

CURRENT PROVIDER

My monthly bill is approximately:

Type of Service

Bundled with:

Satellite

Phone

Both

 

Satellite TV Service

 

I don't satellite tv and I don't want it.  (PLEASE SKIP TO NEXT SECTION)

CURRENT PROVIDER

My monthly bill is approximately:

Bundled with:

Internet

Phone

Both

Number of receivers:

Months left on contract

I currently have:

HDTV

DVR

 

Home Security Service

 

I don't home security service and I don't want it.  (PLEASE SKIP TO NEXT SECTION)

I don't home security service, but I am interested in more information.

CURRENT PROVIDER

My monthly bill is approximately:

 

Video Phone Service

 

I am interested in learning more about video telephones with unlimited calling.