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Application for National Broadband Residential DSL Services

Contact Information

Contact Name for this DSL order (required):
Name to which telephone service is billed at DSL installation site, if different:
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 (required):
 Other phone:
Fax:
 E-mail:

How did you learn of PatriotNet?

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

DSL Service Desired

DSL Service Level:

Installation & Activation Fee:

DSL Modem Fee:

E-mail Account Username:
In addition to a dedicated DSL access circuit, PatriotNet will also include an Internet e-mail 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.  Your e-mail address will be username you choose@patriot.net

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:
Comments:

Installation Site Specifics

Primary operating system on computer 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 an Ethernet card (NIC) installed on your computer? (If the answer is no, please have one installed before submitting this order for DSL):
 Location of telephone company box - network interface device (NID):
For ADSL: How many phone outlets (jacks) are in use on the phone line you wish to use for ADSL service?:
 For ADSL: Are there any devices directly wired to your phone line, such as a security system, intercom, medical monitoring device, etc.?
For ADSL: Do you wish to require a signature upon delivery of the DSL JumpStart Install Kit? (Note: if you waive this requirement, or authorize the package to be delivered without a person to accept it, Covad is not responsible for Install Kits lost in shipping.) Kits can be shipped only to the DSL installation address.

This form completed by:

PatriotNet National Broadband TeleSurfer ADSL Contract

Please click here to read the contract, and click the "I agree with terms - submit this application" button at the bottom of this page to complete your application.

If submit button is not visible, please call 703-691-8122 for assistance.

 

The Next Step

If you agree with the terms above, click the button below to submit this information to PatriotNet for processing.
PatriotNet will order your DSL service through Covad Communications. You will be contacted at the email address you provided to let you know when phone company and/or Covad technicians have scheduled work at the installation location, if applicable - please allow 2 to 6 weeks for service activation.
We will also mail an invoice after DSL service is activated, which must be paid within 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