REQUEST A
FREE SITE SURVEY
Customer Name:
Date:
Address:
Phone:
City:
Cell/Work Phone:
State:
Illinois
Iowa
Minnesota
Wisconsin
Zip Code:
House or Fire#:
Permission to test from roof:
Yes
No
Convenient time to contact:
Current ISP:
Reason for Change:
Number of PC's:
Computer Type:
Desktop
Laptop
Mac
PC
Internal Network:
Yes, Wired Network
Yes, Wireless Network
Yes, Wired and Wireless Network
No
Does your computer
have a network card:
Yes, Internal Network Card
Yes, External USB Device
No
Do you have a Router:
Yes
No
Location of Computer/Router:
Directions to Location:
