DSL Service Request Form

General Information

*Customer Name:
*Physical Address:
*SW Texas Phone:	- -
Other Phone:	- -
E-mail Address:

Service Information Is this request for new or upgraded service? New Upgrade
Is there more than one phone line and number at this location? Yes No
By checking ‘No’ your DSL service will be installed on the phone number in the General Information section.

On which line/number do you want your DSL service installed? (830) -

Please check one item below and fill in the requested information.

I do not want a Southwest Texas Telephone e-mail account.
I want a Southwest Texas Telephone e-mail account.

NOTE: User Name and Password must be 5-10 characters long, are case sensitive and cannot contain spaces or special characters like ‘&’, ‘*’, or ‘!’. Select a user name relevant to you, e.g. Tom Smith might choose ‘tsmith’. Your password keeps others from viewing your e-mail, so keep it secure and don’t share it with anyone.

*User Name: @swtexas.net
*Password:
*Please reenter your password:

Please select the connection speed you want.
Not sure? Watch a DSL speed demo.

Select Connection Speed
Cost per Month	Bronze $19.95	Silver $29.95	Gold $39.95	Platinum $49.95	Diamond $59.95
Upstream	128 kbps	256 kbps	384 kbps	768 kbps	1 Mbs
Downstream	256 kbps	768 kbps	1,500 kbps	3 Mbps	6 Mbps

Additional Information Is your computer equipped with a Network Interface Card (Ethernet ready)?   Yes   No
Do you have any outside extensions on this line/number?   Yes   No NOTE: The $100 installation charge is waived if the customer commits to retain the service for a period of one year. The charge will be applied if the service is disconnected for any reason during the first 6 months period.
I have read and agree to the conditions of the SWTTC acceptable use policy for ADSL service.
Yes   No   view policy