DATE: ________________        BILLING NUMBER: 503.845. _______     BROADBAND NUMBER: 503.845. _______
NAME: ___________________________________________________________________________________________
SERVICE ADDRESS: _______________________________________________________________________________
BILLING ADDRESS: _______________________________________________________________________________
Please check the applicable BROADBAND INTERNET Service:

BROADBAND SERVICE, INCLUDES INTERNET
SmartChoice Bundle - Residential
Includes 640K high speed internet, local access line, Call Waiting, Call Forwarding, Three Way Calling, and Caller ID
$ 49.95 mo.
SpeedChoice Bundle - Residential
Includes 3.0M high speed internet, local access line, Call Waiting, Call Forwarding, Three Way Calling, and Caller ID
$ 57.45 mo.
XtremeSpeed Bundle - Residential
Includes 3.0M high speed internet, local access line, Call Waiting, Call Forwarding, Three Way Calling, and Caller ID
$ 69.95 mo.
Silver - ADSL 640 down/256 up Kbps.
$ 42.95 mo.
Gold - ADSL 3.0 Mbps down/1Mbps up
$ 49.95 mo.
Diamond - ADSL 6.0 Mbps down/1Mbps up
$ 59.95 mo.
Platinum - SDSL (For DATA only) 2.0 Mbps down/2.0 Mbps up
$130.00 mo.
Static IP Address (SEE QUESTION 6, BELOW)
$  8.00 mo.
Non-Recurring Charge (New mtangel.net customers only)
$ 15.00
Customer Request Charge
$ 10.00
Modem with one in-line filter (Regular price $64.95)
Free
Wireless Modem/Router.
$ 69.00
In-line filters, price each
$ 3.90
Activation fee is $99.00. Activation fee is waived when customer commits to retain service for a minimum 12 month period. If service is disconnected for any reason during the 12 month commitment period, the installation charge will apply.
I understand and agree to the Terms and Conditions of the BROADBAND INTERNET Service Agreement.
__________________________________________________________________________________________________     
Authorized Signature            Date
PLEASE ANSWER THE FOLLOWING QUESTIONS:

1) How many telephones do you have on that line? ____

2) Do you have any wall phone jacks? ____ Yes ____ No   How Many? ____

3) Does your computer have a NIC card? (Network Interface Card) ____ Yes ____ No

4) How many computers will you be hooking up to DSL? ____ For multiple computers, the wireless modem/router can be used with up to four (4) wired computers and more than one hundred (100) multiple wireless connections. The wireless modem/router includes a one year warranty.

5) Do you have a telephone jack with dial tone at the location the DSL modem will be set? ____ Yes ____ No

6) For Static IP Address, what is the MAC Address of the equipment that will have the Static IP on it?