Basic DSL Order Form

Please input the following information, Shasta.Com will review it and contact you regarding your installation date.

Your Full Name


Business Name
Optional


Your Street Address
Please use address where service will be located


Suite or Apartment Number
Optional


City


Zip Code


Your Telephone Number
Please use telephone number at service address, if you are ordering ADSL, please use a telephone number that is not part of a centrex group or PBX system.


Your E-Mail Address


Referred By (If applicable)


**You must have a valid AT&T phone line for the duration of the term.

It is necessary to have one of the connections below available for the DSL modem.

Does your computer have USB ports available?
Yes No Don't Know

Does your computer have an Ethernet Card installed?
Yes No Don't Know

Is IDSL service acceptable to you if the product you are ordering is not available in your area?
Yes No

You have chosen the Basic DSL plan with a $22.95 monthly.

Do you want us to ship your modem ($9.95)?
Yes No

Payment Method
Bill my existing Shasta.com account
Credit Card  Exp:

* Modem must be returned when service ends or is canceled, otherwise $100.00 fee for modem shall apply.

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