CUSTOMER INFORMATION
Name (Last Name/First/M.I.)
Occupation and/or Position
Company/School
Nationality Sex
Birth Month Day Year
Home Tel. Office Tel.
Fax.No. Other Contact Nos.
Nickname
Address House No./Street
City Zip Code
Commercial Establishment
Billing Address
Pack
Other Info: Sky Cable Subscriber Yes No
Switcher from what ISP
Maintaining another ISP Yes No
What ISP?
Source:
Computer Type Processor Type
Operating System Modem Brand
Modem Speed No. of phone lines at home
Account used for
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