Wireless Service Submit Form

Please enter the following Information so we may check your

location for service availability or installation.

Are you requesting a site survey or placing an order?:   Select... Survey Order

Please provide the following

Contact information:

          *Required Information

Please specify your location is a business or residence:

Location Type

Select... Residence Business

Closest intersection/Nearest cross street:

Latitude and longitude if you have them:

Are there any trees or large buildings around the service location?:

Yes No Other

If yes please explain:

Choose your preferred Service Level:

Select... 1.5Mb/1.5Mb 3Mb/3Mb 6Mb/6Mb

Questions, Comments?

Would you like to have someone contact you right away?

How did you hear about us?

Online Recommended by another customer Flyer Road Sign Other

Creative Wireless, Inc..
Copyright 2011 [Creative Wireless, Inc.] All rights reserved.
Revised: 9/22/11