Residence                Business                At-Home Business

Physical Address:       Township: Choose One Township Camp Creek Chimney Rock Colfax Cool Springs Duncan Creek Gilkey Golden Valley Green Hill High Schoals Logan Store Morgan Rutherfordton Sulphur Springs Union

City:       State:        Zip:

1.  How many computers do you have?

2.  Do you have Internet?    Yes    No        If Yes, What type of service:

        Dial-Up                                            Cable                   

        DSL                                                Satellite

        DSL Lite                                         Wireless               

        T-1, How Many?        Other:

3.  Who is your Internet Service Provider?

        Internet Blueridge                              RFCI (Rutherford County Internet)

        BellSouth                                         Northland Cable

        AOL                                                MSN

        Earthlink                                            Other:

4.  What do you currently pay per month for Internet Service?

5.  What would you be willing to pay for Internet Service?

6.  If you do not have high-speed Internet, would you like this service? Yes    No    N/A

        a.  Is high-speed Internet currently available at your location? Yes    No

            Unknown    If Yes, who is the Internet Service Provider?

        b.  Do you currently have cable TV? Yes    No

            If No, is it because it is not available? Yes    No

This information will only be shared with local Internet Service Providers and Foothills Connect for the sole purpose of deploying high speed Internet.
                          Your contact information may provide quicker service to your location.

Last Name:    First Name: 

Mailing Address:

City: State: Zip:

Phone:     Email: