US Net US NET DSL ADDRESS QUALIFICATION

Enter the information below to find out if US Net DSL is available at your address. Alternatively, you may call US Net Sales on
1-888-592-4678 or email sales@us.net.

Provide Customer Information
1. Customer Name

  [Your Name]*

  [Your email address]*

2. Address & Telephone Number To Be Qualified

  [Address to be qualified]*

  [Suite, Apt. #]

  [City]*

  [State]*

  [Zip Code]*

  [Telephone number at this address]*

Address & telephone number are necessary to determine availability at your location.

  (* indicates a REQUIRED field )