SuccessNet - Your Community Based Internet Service Provider

DSL Request Form

Please provide the following contact information to see if you qualify for DSL. If you qualify for SuccessNet DSL Service, an account representative will contact you:

Name:

Organization:

Address:

City:

State:

Zip:

Work Phone:

Home Phone:

E-mail:

Your local phone company: (We can only offer service to SBC or Verizon customers at this time.)
Most DSL service uses an existing phone line. What is the phone number of the line you want to use for DSL?
If you need more than one IP address, how many do you need.
Type of service:	Static IP Dynamic IP

If this is for an office please provide current computer setup
(number of workstations, servers etc..):