Rural Tech Solutions Service Request
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address (Service Address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you requesting service for Indian Acres?
*
Yes
No
Please select your glen number :
Please Select
Glen 1
Glen 2
Glen 3
Glen 4
Glen 5
Glen 6
Glen 7
Glen 8
Glen 9
Glen 10
Glen 11 A
Glen 11 B
Glen 12
Glen 13
Glen 14 A
Glen 14 B
Glen 15
Glen 16
Glen 17
Glen 18
Please enter your lot number :
Type of Service Requested? (Select all that apply)
*
Residential Service
Business Serivce
Business Backup Service
Digital Voice
How would you describe your typical internet usage? (Select all that apply)
*
Casual Browsing
Email
Streaming
Gaming
Telework
VPN Required
Teams / Zoom Meetings
Who is your current internet service provider?
*
Satellite Provider (Hughes, ViaSat, Etc.)
LTE/5G Hotspot
Verizon DSL
No Current Provider
Other
How would you rate your current provider?
1
2
3
4
5
Submit
Should be Empty: