DSL Request Form

 

Please submit the form below to see if qualify for DSL service from ConnectNC, INC. This request does not obligate you to purchase. DSL service area is limited to customers within about a three mile radius of Embarq central offices in selected areas or any customers with Windstream local phone service. If you are unsure, please fill out the form, and we will check your distance.

 

                                                                                                                                                   *Denotes a required field.

 

*First Name: *Last Name:
       
*E-Mail: *Current Customer? YesNo
   
*Account Type: Residential Business  Company Name:
       
*Address: *City:

**NOTE** Please enter your Physical Address Above, No P.O. Boxes Please.
       
*State: *Zip Code:
       
Telephone: Fax :
       
*Telephone No. Where DSL Will Be Installed:

 

**NOTE** Telephone numbers should be in the following format: xxx-xxx-xxxx
   
*Local Telephone Phone Service Provider:

   
*How Did You Hear About Us?

       
 

*Method of Contact:

 
       

Questions/Comments: