Name: *
Contact Telephone: *
Alternate Telephone:
Physical Address: *
City: *
State: *	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zipcode: *
Billing Address (if different):
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zipcode:
SSN:
Email:
Number(s):
Convert Local Service?	No Yes
Current Local Carrier:
Phone Package (Includes unlimited long distance):	DTI Basic (No Features) DTI Deluxe (Caller ID, Call Waiting, Call Waiting ID) DTI Complete(Caller ID, Call Waiting, Call Wating ID, Voicemail)
Local Features (additional charges may apply):	Caller ID Name & Number 3 Way Calling Call Waiting Call Waiting ID Speed Calling Call Transfer Last Call Return Distincitve Ring Call Forwarding Continuous Redial Voice Mail Linebacker
Convert Long Distance?	No Yes
Current Long Distance Carrier:
8xx Service?	No Yes
8xx Number:
8xx Ring To Number:
Dial-up Internet?	No Yes
Currnet Operating System:	Windows 98 Windows ME Windows 2000 Windows XP Windows Vista Macintosh Linux
Are you interested in a high-speed internet connection?	No Yes
Comments:
Electronic or Paper Billing? *	Paper Bill Only E-Bill Only Paper & E-Bill