Qwest DSL Order Form

UW is no longer offering Qwest DSL service.

Qwest DSL Services at the University of Wyoming
(all Qwest promotions apply. See current promotions at www.qwest.com/residential/products/dsl/index.html)

1. Name __________________________________________________
   
   
2. W Number: __ __ __ - __ __ - __ __ __ __
   
   
3. Telephone number where DSL is to be installed: ( __ __ __ ) - __ __ __ -__ __ __ __
   
   
4. Name on Qwest Phone Account _________________________________________
   
   
5. I can be reached by phone between 8 am and 5 pm at: 
   ( __ __ __ ) - __ __ __ - __ __ __ __
   
   
6. E-mail address:
   (to be used to provide updates on the status of your service order)
    _________________ @ uwyo.edu
   
   
7. Qwest DSL service type and contract term
   
   Note: not all speed options are available to all telephone numbers as loop qualification results will determine which speeds are available.
   
   

   Qwest DSL Service Type	Activation Fee*	Month to Month Rate**
   Qwest DSL 256 Kbps (256 Kbps down, 256 Kbps up)	$99.00	$15.00
   Qwest DSL Deluxe 640 Kbps (640 Kbps down, 256 Kbps up)	$99.00	$28.00

    

8. Shipping Address, for modem shipment 
   (note: Qwest does not ship to PO boxes)
   
   Name:_____________________________________________________
   
   Street:____________________________________________________
   
   City: ______________________________________________________
   
   State:________________________ Zip Code: _____________________
   
   
   Billing Address:      same as shipping address
   
   Name: ____________________________________________________
   
   Street:____________________________________________________
   
   City: ______________________________________________________
   
   State:________________________ Zip Code: _____________________
   
   
   
9. Computer requirements checklist (check one response for each statement)
   
   

   My computer is a:	Desktop   Laptop
   My computer runs:	Windows XP
   	Pentium Win 98/2000/Me   Pentium Win 95/NT   Mac 8.5 or higher   Linux/Unix/DOS



10. Microfilter information (required for each telephone in use)
    Note: for phone jacks using splitters for multiple phones, count as only one phone device.
    
    How many wall mounted telephones do you have? ________
    
    How many other telephone devices do you have (desk phones, answering machines, fax machines, computer modems, utility  monitoring devices, DSS satellite receivers, burglar alarms)? _______
    
    Note: Qwest needs this information so they can send the correct number of microfilters with your modem. Each device connected to the phone circuit needs a microfilter so it will not interfere with the DSL transmissions and visa versa.
    
    Additional charges apply if you have more than 1 wall mounted telephone or more than 3 other telephone devices.*
    
    
    
11. Modem options (select one). Billed by Qwest *
    External modem, Actiontec 1520 (single PC or multi-user, Ethernet Switch/USB combo)
    
      Purchase modem for $59.99
    
      Rent modem for $5 per month
    
      No modem needed (already have compatible modem)
    
    
    
12. Modem installation options (select one). Billed by Qwest*
    
      Self-install modem, Price: No Charge
    
    Note: detailed instruction guide and Qwest MegaBit installation technical support number are included)
    
      Qwest technician, Price: $150*
    
    Time preference (check one):    8am - 12pm  or    12pm - 5pm
    
    Weekday preference (check one): Mon  Tues  Wed  Thurs  Fri
    
    Note: you will be contacted by Qwest to arrange an installation appointment.

*Qwest pricing is subject to change without notice. Contact Qwest for current prices.

Accounts will normally be active within five working days after a contract is signed.