WINspeed Pre-Order Verification Form

CSR: _________________
Date: _______________

Contact Name_____________________________________________ Phone____________________________

Customer/Business Name_____________________________________________________________________

Physical Address____________________________________________________________________________

Billing Address______________________________________________________________________________

City State Zip_______________________________________________________________________________

Main Billing Phone #_________________________________________________________________________

Does WIN have permission to access your Qwest Customer Service Record via the IMA system? Yes or No

Date:______________________________ Authorized By:___________________________________________

Computer Requirements

Please return completed form to:

Western Iowa Networks
112 E Main St., P.O. Box 280
Breda, IA 51436
office: 888-508-2946
fax: 712-673-2800
Notes: The customer/business name should be the name that Qwest bills (needed for Address Verification in the Qwest system). Physical Address needs to include the street directional (i.e. N, S, E, or W). Please verify correct spelling! The Main Billing Phone # must be the main phone number into any residence or business being billed by Qwest. It won't necessarily be the phone number that we will be putting the line sharing on (we will get that information later).