Name:

Business Name:

Physical Address of Service:		City:
		State: Colorado
Billing Address:		City:
		State:
		ZipCode:

Email Address:

Contact Telephone:

Fax Number:

Do you have a phone system, alarm system, or long distance blocking system?		Yes:
		No:

What speed would you prefer to have? * Please circle your choice! Speeds may vary due to phone line quality!
256k/128	768/256k	1.5M/256k

** Note: Phone systems, alarm systems and long distance call blocking systems "block" the DSL signal preventing it from working. Special wiring may be required if you place DSL on a phone number that runs through a phone system or alarm system, which would require paying a third party to do such work. If you have any questions regarding which line should be used for DSL please call VailNet.

DSL service telephone number: (970)____________________________

Signature: _____________________________ Date: __________________

*Name and Signature must be the individual currently responsible for the local telephone service account.

Your signature constitutes your authorization to VailNet/ColoradoNet to place a firm order with the telephone company for the provisioning of telephone work necessary to provide you with DSL Service. Your signature further acknowledges your understanding and agreement to pay a $50.00 non-refundable processing and telephone line-provisioning fee for this work. In the event the service is terminated by the customer prior to completion of the DSL order this $50.00 fee will not be refunded.

Credit Card #:__________________________________________________________ Exp:____________________

A Visa, MasterCard, or American Express must be provided before VailNet will place DSL service on your phone line.

VailNet/ColoradoNet Box 2812, Avon, CO. 81620 970-949-3318 voice 970-949-3380 fax