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Date

Name *

First

Last

Email *

Alt Contact *

Phone *

Alternative Phone # *

Referred By:

Friend, Neighbor, Existing Customer Referral

Do you own or rent? *

If renting, you must obtain a letter of permission for us to be on the property to do an estimate or install your service.

Mailing Address *

Address Line 1

City

State

Zip Code

Physical Address *

Address Line 1

City

State

Zip Code

Internet - Residential*

*All prices subject to change & do not include installation, taxes or applicable fees.

Telephone Services - Residential*

*All prices subject to change & do not include installation, taxes or applicable fees.

Internet - Business*

*All prices subject to change & do not include installation, taxes or applicable fees.

Telephone Services - Business*

*All prices subject to change & do not include installation, taxes or applicable fees.

Comment or Message

1. Are there any animals on the property that we need'to be aware of? *

2. Is there any equipment outside that can't be reached without encroaching on the neighbor's property? *

3. Is there any landscaping that must be removed prior to construction? *

4. Are there any unsafe or unsanitary areas on or near the location? *

5. Are there any locked gates or fences that we must have access to? *

Checkboxes

All prices subject to change & do not include installation, taxes or applicable fees.
Kit Carson Internet bill is not included with electric bill.
By submitting this application, customer is allowing KCI to enter property for estimate.