Northcentral Connect - Fiber Interest

First Name *

Last Name *

Service Address *

City *

State *

Zip *

Is your Mailing Address different than your Service Address? *

Yes, they are different.

No, they are the same.

Mailing Street Address *

Mailing City *

Mailing State *

Mailing Zip *

Email Address *

Home Phone

Cell Phone *

Who is your current Internet Provider? *

Who is your current Phone Provider? *

Who is your current TV Provider? *

What streaming devices do you use? *

Google Chromecast

Roku

Apple TV

Smart TV

Amazon Fire Stick

Other

I don’t stream currently.

How did you hear about Northcentral Connect? *

Door to Door Salesperson *

Friend’s name *

Other Description *

Questions? Comments?

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