First Name	Last Name
Username	Password

E-mail Address:

Phone number of your contact person:
() x

Broadband:

  DSL      Cable      Wireless      Satellite   

  Firewall Included       DHCP         Static IP     PPPoE

 Other: 


# of Email Accounts
Download Speed KB/sec
Upload Speed KB/sec

-Broadband URL
-DSL URL
-Cable URL
-Wireless URL

  Residential     Small Business     Business

Dedicated:

  DSL    T1(DS1 or E1)    Fractional T3(DS3 or E3)    T3(DS3 or E3) 
  Frame Relay 

Dial-up:

  28.8      33.6      56k      ISDN Service

List area codes and/or country/city codes in which you offer dial up service:

• If your service areas are located in areas covered by the North American Numbering Plan, enter the area codes only, e.g. 508, 800, 619
• If your service areas are located in areas NOT covered by the North American Numbering Plan, please list country code and city code (if applicable) in this format: +44-01, +44-0519, +852)
• If your POPs are located in areas covered by the North American Numbering Plan, enter the area codes only, e.g. 508, 800, 619
• If your POPs are located in areas NOT covered by the North American Numbering Plan, please list country code and city code (if applicable) in this format: +44-01, +44-0519, +852)
• In all cases, please separate code entries with commas.

If you have questions about this form please contact The Lists Administrator at thelist@internet.com.
Submit your info to "The List" for .