Service Lead Form

Please ask the potential customer the following questions and then fill out some basic contact information for them so that one of our sales representatives may contact them.

Phone

What Services are you Interested in? *

Internet

Phone

Video

Check all that apply.

Who is your current Internet provider?

Suddenlink

AT&T Uverse

AT&T Fiber

Charter

Windstream

Other

Who is your current TV provider?

Suddenlink

AT&T Uverse

AT&T Fiber

Charter

Streaming Provider (Amazon Prime, Netflix, etc.)

Other

Check all that apply.

First Name *

Last Name *

Phone Number *

Email Address *

Street Address *

City, State *

Zip Code

Contractor First & Last Name *

Please type your full name here.

Tech ID # *

Please type your tech # here.

Contractor Email Address *

Please enter your email address here.

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