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Rural Wireless – Free Site Survey

Thank you for your interest in our Hi-Speed Wireless Internet Service. Please help us by filling in the following details.

Name: E-Mail: Home Phone: Work Phone: Street Address: City: State: Zip:

What service are you current using?

Dial-Up DSL Cable Modem Satellite None

How did you hear about us?

Internet Search
Referral
Advertisement
Phone Directory
Other

Do we have your permission to conduct a site survey,
which may involve getting on top of your roof?

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