PacInfo Internet Solutions - Internet Access

INTERNET ACCESS

DSL with Qwest

DIAL UP

REFERRAL PROGRAM

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-- ThePacInfo Staff" %> <% End If %>

DSL ACCESS with New Edge Networks
DSL with New Edge « Promotions | Qualify Form

PRE-QUALIFICATION FORM: Please provide the following information
Once you complete and submit, we will use this information to test your line and send the test results to you by email.

Select DSL Provider:*	Select Service Type:*
Name:* " size="30">	Street Address:* " size="75">
Phone:* " size="30">	City:* " size="30">	State:*	Zip:* " size="10">
Email:* " size="75">

Notes: (optional) <%=Session("notes")%> How did you hear about our DSL Service? (optional)
Newspaper Insert Newspaper Ad Website	E-newsletter Email from PacInfo Letter by Mail	Brochure Referred by: " size="20"> Others: " size="26">