STANDARD TELESPEED
 
Internet Services > Sign-Up Forms > DSL(Business)

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Application for Standard TeleSpeed Business DSL Internet Access

Contact Information

Contact Name:
Organization Name:
Street Address of Installation Site:
City:
 State:
 Zip code:
Billing Contact, if different from Contact Name above:
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?
If referred, by whom?
Sales Representative:
This form completed by:

DSL Service Desired

DSL Service Level:
Activation/Installation Payment Option:
Customer Equipment Needed:
Comments:
Domain Name to Associate with this Circuit, if any:

Enter a domain name (no more than 23 characters in length) followed by .com (businesses) or .org (organizations):

First choice
 Second choice
InterNIC domain name registration fees billed separately by Network Solutions, Inc.
Register or Transfer?

Add Unlimited Domain Email?
Yes, add an Unlimited Domain Email Package to this service for no additional charge. This package may be added at any time after your domain name is transferred to PatriotNet, and gives you an unlimited number of email boxes to use with your domain name, so that you have as many addresses @your_domain_name as you need!
Email Addresses Needed @ Domain Name Above:

Dial-up Account Username:

In addition to a dedicated DSL access circuit, PatriotNet will also include a dial-up Internet access account which you may use as desired. 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. 

First choice
 Second choice
Dial-Up Operating System: Please specify the operating system of the machine from which you may wish to connect using the included dial-up access account:
If "other", please specify:

Installation Site Specifics

Building Type:
 Do you authorize Covad technicians to perform inside wiring, if needed? (Minimum charge: $91.50)
Preferred install time:
 Primary operating system for computers to use DSL connection:
Location of telephone company box - network interface device (NID):
How many IP numbers will be needed (how many computers will be connected)?

The Next Step

Click the button below to submit this information to PatriotNet for processing.
PatriotNet will check for circuit availability and contact you to let you know when the DSL service is scheduled to be available in your area.
We will also provide a service contract to be completed before the service is installed. The activation/installation charge and first month's service fee will be due after installation is complete.

Please call PatriotNet at 703-691-8122 with any questions regarding this order.

PatriotNet
9990 Fairfax Blvd, Suite 500
Fairfax, VA 22030