KansasNet DSL Order Form

KansasNet DSL Order Form for Embarq/Sprint Territories

Installation Total: $_______________

Equipment Total: $ _______________

Monthly Service: $_______________

Commitment: _____ Months

(Please answer the following questions)

Date:_ / _ / _______

Note that certain service types and minimum connection rates are not available in all areas. Consult your sales person for availability.

Circle the dollar amount associated with the service type you want.

Speed Class	Downstream (bps)	Upstream (bps)	Single-PC	2-4 PCs	5-9 PCs	10+ PCs
Bronze Residential*	Up to 256k	Up to 128k	$24.95/mo.¹ $34.95/mo.²	$29.95/mo.¹ $39.95/mo.²	$39.95/mo.¹ $49.95/mo.²	ASK
Bronze Business^§	Up to 256k	Up to 128k	$34.95/mo.¹ $44.95/mo.²	$39.95/mo.¹ $49.95/mo.²	$49.95/mo.¹ $59.95/mo.²	ASK
Silver Residential*	Up to 512k	Up to 128k	$29.95/mo.¹ $39.95/mo.²	$34.95/mo.¹ $44.95/mo.²	$44.95/mo.¹ $54.95/mo.²	ASK
Silver Business^§	Up to 512k	Up to 128k	$39.95/mo.¹ $49.95/mo.²	$44.95/mo.¹ $54.95/mo.²	$54.95/mo.¹ $64.95/mo.²	ASK
Gold Residential*	Up to 1.5M	Up to 384k	$34.95/mo.¹ $44.95/mo.²	$39.95/mo.¹ $49.95/mo.²	$49.95/mo.¹ $59.95/mo.²	ASK
Gold Business^§	Up to 1.5M	Up to 384k	$64.95/mo.¹ $74.95/mo.²	$69.95/mo.¹ $79.95/mo.²	$79.95/mo.¹ $89.95/mo.²	ASK

¹ Indicates monthly pricing for new subscribers with a 1-year term commitment. An Early Termination Fee (ETF) will be applied for any service cancelled prior to the termination agreement date. The Early Termination Fee will equal $249 or your monthly service rate times the number of months left in your service agreement, whichever is less.
² Indicates monthly pricing for new subscribers without a 1-year term commitment. A $149 additional one-time setup fee applies when you choose service without term commitment; this additional fee must be paid in full upon service agreement.

* Indicates rate applicable for residential telephone lines only (rate not available for business-lines, see below).
^§ Indicates rate applicable for business-grade telephone lines.

Verify Number of Devices to be connected (not including your router): _____

DSL Modem Install Kit (circle one):

SINGLE-PC ONLY with 1-year commitment:	$59 Standard DSL modem
MULTIPLE-PC with 1-year commitment:	$59 DSL modem with Integrated router feature enabled $99 DSL modem with Integrated router & Built-In 4-port switch
SINGLE-PC without commitment:	$99 Standard DSL modem
MULTIPLE-PC without commitment:	$99 DSL modem with Integrated router feature $139 DSL modem with Integrated router & Built-In 4-port switch

PCI Network card needed (additional charges may apply) : YES NO

Number of phone jacks used in house/building (i.e. for telephones, answer machine, security system, FAX): ____

Number of phone line filters needed (up to 3 included for no charge, additional filters $10/ea.): ____________
What kind of IP addressing scheme do you want? Dynamic Static # of IPs _______

(Note: static IP addresses are an additional $10/month/address and are not included with this service.)

End-User Information

End User Name ________________________________________________________________

Service Address ________________________________________________________________

City, State, Zip ________________________________________________________________

DSL Telephone Number ________________________________________________________________

Contact Name ________________________________________________________________

Contact Phone Number ________________________________________________________________

I, the undersigned, realize that this is an obligation for KansasNet DSL service. I am authorized to, and do agree to commit (name of end user, or company) _____________________________________ to the payments (based on my selections in this document) for this service. I realize that the early termination fee for this service is $249 or the monthly service fee multiplied by the number of months remaining in the commitment, whichever is less. I understand that I may also be charged a Tax Recovery Fee, which is the recovery of tax that KansasNet must pay when KansasNet purchases the DSL circuit from the telephone company. By signing this, I also confirm that I have read, and do agree to KansasNet’s document titled “KansasNet Terms of Access.”

Customer Name (Printed) _____________________________________

Customer Signature ______________ Date

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Note: DSL Internet services are provided by Kansasnet. Monthly pricing includes GSP charges. A Tax Recovery fee may apply. Regular voice telephone line and service not included. One-time charges for hardware, installation & service order may apply. Early termination fees and other restrictions apply. Additional charges may apply for installation and non-standard wiring or other inside work or equipment required. KansasNet DSL, or it’s various options may not be available in some areas due to factors associated with DSL technology such as line conditions or distance. Connection speed is between customer premise and the DSL-equipped serving central office or DSL gateway. Actual connection speeds may vary. Network connections may require higher-end DSL services, additional products and services, and/or more than one DSL connection. The service is not guaranteed to work until the technician installs and tests the service.

NOTES:

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Date:___ / ___ / _______

Circle the dollar amount associated with the service type you want.

Customer Name (Printed) _____________________________________

Customer Signature ______________________________ Date________________

Date:_ / _ / _______

Customer Signature ______________ Date