Connect SI

Broadband Request Form

First Name
Last Name
Business Name (if applicable)
   
Mailing Address
City      
State
ZIP Code
   
   
Service Address (if different)
Service Address City (if different)
Service Address State (if different)
Service Address ZIP Code (if different)
   
If your service address is a Rural Route Address, P. O. Box, or other non-911-style address, please provide directions from the nearest major landmark.
   
Phone Number
Best Time To Call
Email Address
   
Do you already have Internet service at this location? If so, what kind of service do you have at present?
I don't have any Internet service at this time.
Dial-up
DSL
Cable Modem
Fixed Wireless
Satellite
Other Internet
   
Is this service for your home, or for your business? Home    Business
   
Do you have any other special needs, or are there other Internet-related services in which you are interested?
I am interested in Web site hosting.
I am interested in eCommerce (selling my goods or services online).
I use my connection to send or receive large files (large graphics, blueprints, professional audio or video)
I am interested in VOIP (Voice-Over-IP, using my Internet connection to supplement or replace traditional phone service)
I am interested in server co-location or dedicated hosting.
 
Are there any other special services you may need, or any other details relevant to your request? If so, please enter them here.


Completing this form is not a commitment on your part to buy service, nor is it a commitment of service by any member of Connect SI. We will send your request to all the Internet service providers affiliated with Connect SI, and any providers who believe they can provide service to you will contact you.


Terms of agreement: I understand and agree that the information I provide will be used by the Internet Service Provider (ISP) members of Connect SI for purposes of evaluating their ability to meet my Internet connectivity requirements. My address information may be used to develop maps to help Connect SI to understand where gaps in Internet availability may exist. I grant approval to the member ISPs of Connect SI to contact me, using the information provided, for the purpose of attempting to provide to me Internet service. Connect SI and its member ISPs will use this information only for these purposes and no others.

Human Subjects: The information will used for GIS mapping and research purposes through a project housed in the Department of Geography at Southern Illinois University Carbondale. No information for this purpose will be released or printed or used to disclose any personal identity and all such research data will be properly secured and destroyed after three years. All information related to participating subjects will be treated in strict confidence to the extent provided by law. The identity of the participants will be coded and will not be associated with any published results. The code number and identity will be kept in a locked file by Mr. Steven Mitchell of Man-Tra-Con, Inc.

Any questions regarding the Human Subjects use of the data may be addressed to Dr. Tonny Oyana at (618) 453-3022 or Mr. Steven Mitchell at (618) 998-0970, ext. 219.
  I agree to the above terms and conditions