National Broadband Business DSL Services

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Application for National Broadband Business DSL Services

Contact Information

Contact Name for this DSL order (required):
Organization Name:
Street Address of Installation Site, as it appears on telephone bill:
City:	State:	Zip code:

Set Up New Billing:	-OR-	Add to Existing Billing:
Billing Contact for DSL (if different from Contact Name above):		Bill to this PatriotNet Billing ID:
Billing Address (if different from street address above):
Billing Address City:	State:	ZIP Code:

Installation Site Phone:	Other phone:
Fax:	E-mail:

How did you learn of PatriotNet?

Additional source description (publication name, referrer's name, etc.):
Sales Representative:
This form completed by:

DSL Service Desired

DSL Service Level:

Activation/Installation Payment Option:

Customer Equipment Needed:

Email Account Username:

In addition to a dedicated DSL access circuit, PatriotNet will also include an Internet email account for your use. Please choose a username between three (3) and eight (8) characters in length, containing only numbers and lower-case letters, and beginning with a letter. The address for this account will be username you choose@patriot.net. PatriotNet also offers domain hosting services for companies wishing to use their own domain name with their email and/or Web site; please click "Web Hosting" on the PatriotNet Web site for details.

first choice

second choice

-OR-

Current PatriotNet username to transfer to new service

Email forwarding:

If you do not plan to check this PatriotNet email account, please specify
an email address to which we may forward your PatriotNet mail:

IP Address Options:

Indicate below the quantity of usable static (public) IP numbers required:

Comments:

Installation Site Specifics

Primary operating system for computers to use DSL connection:	Do you authorize Covad technicians to perform inside wiring, if needed? (Minimum charge: $91.50)
Preferred install time:	Building Type:
Do you have a computer network, or an Ethernet card (NIC) installed on at least one computer?	Location of telephone company box - network interface device (NID):

The Next Step

Click the button below to submit this information to PatriotNet for processing.

PatriotNet will check for service availability at your location, and notify you of any problems with your order. We will also provide a service contract to be completed before we schedule installation or activation of service.

PatriotNet will use the email address you provided above to let you know when phone company and/or Covad technicians have scheduled work at the installation location, if applicable. Please allow 3 to 6 weeks for service activation. We will mail an invoice after DSL service is activated, with payment due in 20 days.

Please e-mail sales@patriot.net or call PatriotNet at 703-691-8122 with any questions regarding this order.

PatriotNet
9990 Fairfax Blvd, Suite 500
Fairfax, VA 22030