WARNING: This form is to CHECK for availability, click here to place a ORDER

PubNIX, Inc. - xDSL Availability Verification Request
EMail of requestor: print("value=\"$email\">\n");
Customer Contact Name: print("value=\"$contact\">\n");
Customer Contact Phone Number: print("value=\"$contact_phone\">\n");
Civic Number:
Do not forget about Appt | Suite # 		print("value=\"$civic_number\">\n");
Street Name: print("value=\"$street_name\">\n");
Town: print ("value=\"$town\">");
Postal Code: print ("value=\"$postal_code\">\n");
Phone Number: print ("value=\"$phone_number\">\n");
Must be the phone number corresponding to a phyiscal phone line.
Service Type:
Note: