USAtek Optimal DSL Pre-Qualifier

USAtek DSL PRE-QUALIFICATION
for VERIZON TERRITORIES in Western PA

Please fill out the following Authorization form so that we can have your location checked for service. We will then contact you with the results and if successful, help you get started with your USAtek OptimalDSL service!

What DSL speed are you
interested in:

TIER	BANDWIDTH (Kbits down/up)	TOTAL COST*
512k	512 / 512	$49.95
768k	768 / 768	$69.95

DSL Ordering Instructions:

Qualify only and let me know (DO NOT ORDER)
Qualify and call me to confirm authorization to order

A phone number at the
same location that you want
tested for DSL service:

Your Name:

Your E-mail address:

The physical address of the
location of the telephone
number above:

(ADDRESS LINE 1) - NO P.O. Box

(ADDRESS LINE 2)

(CITY, STATE ZIP)
,

Alternate number to contact you
if not at the number above:

Are you currently a customer of
USAtek?

Yes No

Comments

*Introductory monthly special for new customers only. No other installation or setup fees unless customer requests installation assistance from installer.