CenturyLink QWest Internet | Request New Service | Intelligent Technical Solutions

Customer H Number:*

Requested Due Date:*

Internet Service Package:*

Select Internet Service Speed / Contract Length / Price

Service Site Information

Service Street Address:*

The street address of the site where internet service will be activated. Please include Suite and/or Unit numbers

Service City:*

Service State:*

Service Zip Code:*

Name of Person to Contact at Time of Installation:*

Phone Number of Person to Contact at Time of Installation:*

Do you need CenturyLink to perform any inside wiring installation?:*

Full Tech Install:*

If CenturyLink will be installing a jack, please specify type requested:

Modem:*

IP Address:*

Dynamic IP addressing is included in the Bundle price. If requesting Static IP, additional charges will apply.

Number of Static IP's Legacy Ensemble:*

Type of Configuration:*

List any Additional Features or Blocks desired:

Comments and Special Instructions:

Phone

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