CenturyLink QWest Internet - Request New Service Customer H Number:* Requested Due Date:* Date Format: MM slash DD slash YYYY Internet Service Package:* Select Internet Service Speed / Contract Length / Price Choose an item512K/256K - 24 Months - $54.99512K/256K - 12 Months - $69.99768K/384K - 24 Months - $54.99768K/384K - 12 Months - $69.991.5M/512K - 24 Months - $54.991.5M/512K - 12 Months - $69.993M/640K - 24 Months - $54.993M/640K - 12 Months - $69.995M/768K - 24 Months - $54.995M/768K - 12 Months - $69.996M/512K - 24 Months - $54.996M/512K - 12 Months - $69.998M/768K - 24 Months - $54.998M/768K - 12 Months - $69.9910M/768K - 24 Months - $54.9910M/768K - 12 Months - $69.9910M/1M - 24 Months - $54.9910M/1M - 12 Months - $69.9912M/1.5M - 24 Months - $64.9912M/1.5M - 12 Months - $79.9912M/5M - 24 Months - $64.9912M/5M - 12 Months - $79.9915M/768K - 24 Months - $64.9915M/768K - 12 Months - $79.9915M/1.5M - 24 Months - $64.9915M/1.5M - 12 Months - $79.9920M/1.5M - 24 Months - $64.9920M/1.5M - 12 Months - $79.9920M/2M - 12 Months - $79.9920M/5M - 24 Months - $64.9920M/5M - 12 Months - $79.9925M/2M - 24 Months - $84.9925M/2M - 12 Months - $79.9940M/5M - 24 Months - $84.9940M/5M - 12 Months - $99.9940M/20M - 24 Months - $84.9940M/20M - 12 Months - $99.9950M/5M - 24 Months - $154.9950M/5M - 12 Months - $99.9960M/5M - 24 Months - $154.9960M/5M - 12 Months - $99.9960M/60M - 24 Months - $154.9960M/60M - 12 Months - $99.9980M/10M - 24 Months - $154.9980M/10M - 12 Months - $99.9980M/40M - 24 Months - $154.9980M/40M - 12 Months - $99.9980M/80M - 12 Months - $99.99100M/100M - 24 Months - $154.99100M/100M - 12 Months - $169.99200M/200M - 24 Months - $174.99200M/200M - 12 Months - $189.99300M/300M - 24 Months - $204.99300M/300M - 12 Months - $219.99400M/400M - 24 Months - $204.99400M/400M - 12 Months - $219.99500M/500M - 24 Months - $204.99500M/500M - 12 Months - $219.991Gig/1Gig - 24 Months - $254.991Gig/1Gig - 12 Months - $269.99 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:* Choose an itemAZCOIAIDMNMTNDNENMORSDUTWAWY Service Zip Code:* Name of Person to Contact at Time of Installation:* Phone Number of Person to Contact at Time of Installation:* Service and Installation Configuration Details Do you need CenturyLink to perform any inside wiring installation?:* Choose an itemYesNo Full Tech Install:* Choose an itemYesNo If CenturyLink will be installing a jack, please specify type requested: Choose an itemRJ21XRJ11CRJ45SRJ48SDemarc Modem:* Choose an itemPurchaseLease IP Address:* Dynamic IP addressing is included in the Bundle price. If requesting Static IP, additional charges will apply. Choose an itemDynamicStatic Number of Static IP's Legacy Ensemble:* Choose an itemDynamic IP124816 Type of Configuration:* Choose an itemFilterSplitter Additional Information List any Additional Features or Blocks desired: Comments and Special Instructions: Comments This field is for validation purposes and should be left unchanged.