DSL High Speed Internet Access Qualification
(*)ADDRESS:	Address Apt/Suite #
(*)WHERE T1 WILL BE INSTALLED	City State ===US States=== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Canada Europe ===Canada Provinces=== Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan ZIP Code
(*)E-MAIL ADDRESS:
INSTALLATION (*)TELEPHONE NUMBER:	Installation Phone Number - -