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user_info


Cable Line Speed:
Bronze(15/2)
Silver(40/10)
Gold(60/10)


User Information:

Account Number,(if known):
First Name:
Last Name:

Contact Information:

E-mail:

Phone Number:

This phone number is your?

Home Number
Work Number
Cell Number
VoIP Number

Service Address:

Street Number:
Street Name:

Suite/Unit/Apt:

City:
Prov:
Postal Code: