402 N. Columbia, Coulee Dam, WA 99116, 1.800.572.5678 or 509.633.0830


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ZIPP NETWORK CONNECTION REQUEST

Date:
Full Name:
Business:
Address where Zipp will be connected
  , WA
Uncheck here if your mailing address is different from the one above
Mailing address
  , WA
Own Rent   We must have the signature of the property owner before a request can be processed. Please see Owner/Renter Agreement form.
Owner telephone Home: Work: Mobile:
Renter telephone Home: Work: Mobile:
Is there any life support at the residence? (oxygen, etc) If so, what type?
Do you have dogs? Yes No
If yes, please detail if they are confined and number, types and names of dogs
Contact Person
(if other than owner/renter)  
  Phone

YOU WILL NEED TO HAVE CAT5 CABLING INSTALLED IN YOUR HOME:
I would like a do-it-yourself Cat5 workbook.
I would like to pick my own contractor.
I would like GCPUD to contact a contractor for me.
I would like my service provider to install it.

INDICATE WHICH SERVICE PROVIDERS YOU HAVE SELECTED:
Note: You must select a provider to receive Zipp Network service.
Internet
Service Provider:
Telephone
Service Provider:
Video Service Provider:  

SERVICE INFORMATION: (All conditions of service are subject to our customer service policies)