Citizens Communications : Site Survey Form

COMMUNITY

SITE SURVEY

c3bb Communications Corporation Broadband Wireless

SITE SURVEY FORM
Are you interested in a FREE SITE SURVEY for your home or business? By filling out the form below you will get a free site survey completed by one of our technicians. The site survey will determine if you can get service at your home or business. Please fill out the form below, if you have any questions please feel free to contact our office at 812-752-7204.

Name: *
E-mail Address: *
Address: *
City: *
State: *
Phone Number: *
Secondary Phone Number:
Zip Code *
Type of Service you are interested in: *
Where is your computer located? (Ex: Northeast corner of home) *
How did you hear about us? *
When are you available for installation? *	Someone is normally at the home I would need at least a day notice I need more than a couple days notice Only available in the mornings 8 - 12 Only available in the afternoons 1:30 - 5 Home only on certain days of the week (please specify in comments)
Nearest Crossroad *
County you live in: *
Township you live in:
Comments:



* Required