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WIRELESS SITE SURVEY REQUEST FORM

A site survey is needed to determine if Pass Word's High Speed Broadband can provide you with wireless internet access. A technician will visit your location with special wireless testing equipment. Depending upon the location of our equipment, it may be necessary for our technician to have roof access to determine line of site connection to one of our towers. There will be no charge for our site survey and it will take approximately 60 minutes to complete.

*Indicates required fields

*Contact Name:
Company Name:
Phone:
*Email:
*Address1:
Address2:
*City:
*State:		*Zip:
I am interest in wireless access for:
Number of computers on your network:
Current network connection:
Additional Information:
A Pass Word representative will be calling you shortly to finalize the details of the wireless site survey. You will receive an email confirming we have received your request. If you have further questions please call us at 624-5235 and ask for wireless sales. NOTE: This form is not a contract.