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Essential Services Survey
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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(1) Local/Long Distance Service
Current Local/Long Distance Provider
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Primary Phone Number
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My Monthly Phone Bill Approximately $
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Bundled With
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Internet
TV
Both
Bundled Services Total Bill $
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International Calling
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Yes
No
Long Distance Calling
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Yes
No
I am interested in unlimited calling.
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Yes
No
(2) High Speed Internet Service
Current Internet Provider
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My monthly bill is approximately $
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Type of Service
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Cable
Dial-Up
DSL
Wireless Aircard
Bundled With
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TV
Phone
Both
(3) Digital Phone Service (VOIP)
Do you call anyone who you wish you could see more often?
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Yes
No
I am interested in Digital Phone Service (Unlimited Calling)
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Yes
No
(4) Cell Phone Service
Current cell phone service provider
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I am open to using a different provider
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Yes
No
My monthly bill is approximately $
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Number of minutes on current plan
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Months left on current providers plan
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Number of phones on plan
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Do you currently have a texting plan
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Yes
No
Do you currently have a data plan
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Yes
No
I last upgraded my phone - when
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Choose Any
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I like my handset
I am interested in upgrading my handset
I am interested in service without a contract or credit check
I am interested in a wireless card for my laptop
(5) Mobile Application
Do you make long distance or international calls on your mobile phone?
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Yes
No
Are you interested in saving money on your mobile phone bill?
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Yes
No
(6) TV Service
Current television service provider
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My monthly bill is approximately $
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TV service bundled with
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Internet
Phone
Both
Number of receivers
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Months left on contract
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I currently have
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HDTV
DVR
(7) Home Security & Automation
Current provider
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My monthly bill is approximately $
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I am currently a
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Home owner
Renter
Choose Any
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I do not have home security service but am interested in learning more information
I am interested in home automation service
(8) Computer Support
Current Provider
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Do you perform regular backups of your files?
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Yes
No
Have you ever had a computer virus?
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Yes
No
Amount spent on average computer repair incident $
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Please select the type of computer support services you have used in the past.
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Friend or family member
National Provider
Manufactuer
Remote service
Self help
(9) Energy
Types of service you use
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Electric
Natural gas
Propane
Current service provider/providers
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My monthly energy bill is approximatly $
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I am interested in the following
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Residential electricity
Business electricity
Residential natural gas
Business natural gas
Approximate total of your monthly utility bills $
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