Please provide the following information so we can have more information about your need and bandwidth available to you. 

Please complete all fields. Thank You!

System showing you'r login from:
You'r login from IP Address:

First Name
Last Name
Company
Home Phone
Work Phone		Ext. Number
FAX
E-mail	**
URL

(** Make sure you provide the e-mail address or we would not be able to contact you for the information you requested)
Select One. Wireless will be for  Business Use Home Use

Please give us the location where the wireless service would be installed.

*Street Address
*City
*State/Province
*Zip/Postal Code
Approximately how tall  is the building?	feet
If known, elevation of building?	feet

Direction	Describe Type of Obstruction	Height
North		15-25 feet 25-35 feet 35-45 feet 45-55 feet 55 + feet No Obstruction
North East		5-15 feet 15-30 feet 30-60 feet 60+ feet No Obstruction
East		5-15 feet 15-30 feet 30-60 feet 60+ feet No Obstruction
South East		5-15 feet 15-30 feet 30-60 feet 60+ feet No Obstruction
South		5-15 feet 15-30 feet 30-60 feet 60+ feet No Obstruction
South West		5-15 feet 15-30 feet 30-60 feet 60+ feet No Obstruction
West		5-15 feet 15-30 feet 30-60 feet 60+ feet No Obstruction
North West		5-15 feet 15-30 feet 30-60 feet 60+ feet No Obstruction

I currently access the Internet via:

28.8K Modem 56K Modem 128K ISDN Cable Modem Leased Line Others

My current internet usage consists of:

Email

Web Browsing  

FTP/Video Streaming  

Mail Server  

Web Hosting

Are you running any LAN?   No Yes

How many users will be accessing this wireless connection?   

Bandwidth (speed) you like to have. 384K 512K 768K 1Mbps 1.5M 2.0M more than 2M

* * For survey only, please skip Username and Payment Information.

 

Please type in the following:  (This is for your e-mail service only, please skip this one if you are current wirelesstown.com , cin.net or kewaneeOnline.com users)

Username:		Password:

The username must be lowercase, the first character must be a letter, and may be 5 to 12 characters. It can be a mix of letter and number as well as "-" and "_". You may select your preferred login name in the first came first served condition.  The "username" is part of your email address. If you select "john,"  then your email address will be john@wirelesstown.com. Existing cin.net user or WirelessTown users may keep the same e-mail address.

The "password" is what your need to get into your email and Internet. This must be secure and not be given to anyone. Do not use a dictionary word or a name, from any language, as your password. A good password is a mix of characters and numbers (i.e. 17Gkr# of *3gKDF) Remember, it is case sensitive. The minimum length of password must be 6 characters

Payment Type:

Visa Mastercard Discover American Express Check

**If you select payment by check, your account will not be activated until your payment is received. Click here for the address to submit your payment.

If you select payment by credit card, please sign this credit card authorization form and fax or mail to WirelessTown within 5 days. your account will be herein automatically charged for renewal when your current term expires. You need to contact billing@wirelesstown.com  if you want to change the payment method.

***Please note, your new account would be disabled if this authorization form is not received  within 5 days.

Questions and Comments:
( If you are from rural area, please also provide direction to your location. That will help our field technician to find the place, thanks.)

We will be in touch with you in the near future. Thank you for taking the time to fill out this form! 

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Copyright © 1999 [Wirelesstown.com]. All rights reserved. Revised: April 21, 2002