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DSL Address Verification Form

NOTE: This is only valid for customers in the 757, 804 and 703 area codes. If you do not live in either of the area codes listed, please do NOT submit this request, as we do not service your area.

Please fill in all the blanks below and click the SEND button. Failure to fill in all blanks with the appropriate information will result in this request not being received and processed.

All fields marked with an * are required to be filled out completely. Incomplete requests will not be processed and therefore cannot be replied to.

Residential customers, your phone number must be verifiable as a residence phone line in order to receive residential DSL services.

Please do NOT use ALL CAPS in this application and please input your phone number as indicated to the right of the blanks. This is an automated form and it will not perform properly if you don't fill it out in the correct manner. Here is an example of how it should be filled out:

Name: Fred T. Jones
Organization: FTJ, Inc.
Street Address: 1029 Wake Way
City, State, Zip: Anywhere, Virginia, 22539
Day Phone: 804-555-5555
and so on.

Upon reciept of your request for verification DSL availability at your address we will send you back an email telling you whether we can service your residence or not.

Customer Name: *
Organization: * Not required for residential accounts
Street Address: *
City: *
State: *
Zip: *
Contact Phone: * Example: 5555555555 (Do not put any ( or - or anything in this entry, only numbers all run together.
Phone where DSL to be installed: * Example: 5555555555 (Do not put any ( or - or anything in this entry, only numbers all run together.
Service Type: * Please tell us if you are requesting Residential or Commercial DSL services.
Existing email address: *
System Type: * Must be Windows, Mac, or Linux

Any additional information or comments can be entered in the space below. Please note whether you are inquirying about Residential or Commercial services.

Please process my request for verification of DSL service availability at my address. I understand that residential service is available only for residential accounts, that no Internet servers are allowed on this service, and that service availability is dependent upon all the criteria that are used to qualify my address.
Name:

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