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2. First Name*
3. Last Name*
5. E-mail*

   This e-mail will be used for communications.

6. Phone Number*
8. Driver's License Number*
9. Date of Birth*
   Date of Birth
11. Billing E-mail

    If different than your e-mail used for communications. This e-mail will only be used for billing purposes.

13. Service Address *

    The residential or business address within the City limits where you are requesting new service.

15. Residential Speed Tier Requested
    -- Select One --Tier 1- 50 Mbps $44Tier 2- 150 Mbps $66Tier 3- 250 Mbps $99Tier 4- 500 Mbps $150Tier 5- 1 Gbps $200
16. Commercial Speed Tier Requested
    -- Select One --Tier 1- 60 Mbps $60Tier 2- 250 Mbps $99Tier 3- 150 Mbps +1 Static $150Tier4- 300 Mbps + 5 Static $300Tier 5- 500 Mbps + 5 Static $500Tier 6- 1 Gbps + 5 Static $1000
18. Requested network password*

    Minimum of 8 characters

19. 4 Digit Security PIN*

    This PIN will be used to verify your identity for account needs.

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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field