Please fill out the form below to help us understand your needs.

If you have any questions feel free to call or text the number below.

402-509-8080    

Order Form

Name *

First

Last

Email *

Phone *

Company

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Prefered method of Contact?

• Email
• Phone

Prefered time to call?

Services

• Satellite TV
• Internet
• VOIP / Phone
• WiFi
• Mobile Satellite
• Digital Signage

WiFi Services

• Not sure
• Indoor (Inside Building)
• Outdoor (Patio)
• Private
• Public (Guest Network)

What is your Fire Code Occupancy Limit?

How many Phone lines?

• 1
• 2
• 3
• 4
• 5 or more

Mobile SatelliteTV (RV)Internet (RV)Internet Business Class

What is the Year, Make, Model, Size of Vehicle? How much roof space do you have?

Satellite TV ServiceDon't Know / Don't Have oneDirectvDish NetworkShaw TVBell TV

Type of BusinessNot SureCommercialPublic ViewPrivate

How many TVs will hooked up?

How many devices will be connected to the network?

Do you have any additional requirements?

• Yes
• No

Additional Requirements

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