DSL Trouble Submit Form

  Please enter the following Information.

  Who is your DSL Provider:

  What carrier of service are you reporting trouble on?:   Select... VerizonSBC

  Please provide the following contact information:

*Name
Title
Organization
*Street Address
Address (cont.)
*City
State/Province	CA
*Zip/Postal Code
*Contact Phone
*DSL Phone
FAX
*E-mail

          *Required Information

 What is your PVC number (if you have it)?: 

  Please specify your location is a business or residence?:

Location Type

Select... ResidenceBusiness

  Is there Dial Tone on the DSL line?:

Choose One

Select... YesNo

  Have you had any contact with the billing department for late payments?:

YesNoOther

If yes please explain:

  Have you made any changes to your phone service in the last month?:

YesNoOther

If yes please explain:

  Choose your Service Level:

Select... 768k/128k1.54Mb/128k 1.54MB/256k 1.54Mb/384k 1.54Mb/768k 3.0Mb/768k 7.1Mb/768k

  Choose your modem type:

Select... Fujitsu Alcatel Infinilink Zyxel Other

  What is the status of your DSL modem lights?:

  Do you authorize a Telco dispatch:

Select... Yes No

(A non-Telco problem found will incur a $90.00 min charge)

Questions, Comments?