Comack Internet Service Order Form
Referral Agent
Referral Agent Email*
Full Name*
Phone Number*
Tax ID*
Legal Corp Name*
Service Address*
Is The Billing Address Different?*
No
Yes
Billing Address Line 1
Billing Address Line 2
Billing City
Billing State
Billing Zip
On Site Contact Name*
On Site Contact Phone Number*
Preferred Service Provider*
-- Please choose --
Spectrum
Optimum
Xfinity
Verizon
Best Available
How many Static IPs?*
-- Select --
None
1 Static IP
5 Static IPs
Do you want a router from the ISP?*
Yes
No
Do you want a phone line?*
Yes
No
Comments
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