Name:
Email Address:
Street Address (in Lake City):
PO Box (in Lake City):
Phone:
Fax:    
Business Name (if reporting for a business):
Business Email Address:
Business Web Page URL:
Business Street Address:
Business Phone:
Business Fax:    

If you have a winter address
Address:
City, State, Zip:

YOUR PRESENT TELECOMMUNICATION USE:

How many phone/data lines do you currently have?:
Voice: 
Data:   
Leased Lines: What speed are the leased lines:

Do you want/need or plan on additional lines:  Yes No
           If so, how many:

Do you have a credit card machine:  Yes No
Do you have an active cell phone you would like to use in Lake City:  Yes No
Do you have a satellite modem connection: No Yes

Present internet use:
     How many dial up modems computers using internet:
     How many accounts/email addresses:
     Do you have a Web site: No Yes
          If so, do you take orders via the web: Yes No
     At what modem speed are you connecting: Up to 14,400 Up to 28,800 More than 28,800
          At what speed do you normally connect (if known):
     If your usage is seasonal please indicate the months in which you connect:
                    (choose as many as appropriate): Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec
     On average how much time are you actually connected (on line):
          Per day: Per week: Per month:
     Do you have a dedicated full time internet connection: No Yes
          What speed is the dedicated line:

What are your average telecommunication costs per month
     Voice Total (including long distance):
     Modem/internet total (including any long distance charges):
     Leased line costs per month:

Have you been impacted by "all circuits are busy" messages: Yes No
Please tell us about the impact:

YOUR PROJECTED TELECOMMUNICATION USE:
Do you foresee needing future telecommunications for:

     General internet access: Yes No
          If you do not now access the internet do you plan to do so: Yes No ???
                When: (not specified) within six months within one year
     Teleconferencing/video conferencing: Yes No
     Data backup: Yes No
     Multimedia file transfer: Yes No
     Audio/video on demand (movies, music, interactive games): Yes No
     Distance learning: Yes No
     Other: ??? Yes No
     If yes please explain:

Do you plan to have a web page or additional web pages in the future: Yes No

Would you be interested in local web hosting if there was a server in Lake City: Yes No

If higher speed/greater bandwidth (256K, about 4-5 times faster than 56K modem) connections were available how much more than you are paying now for access would you be willing to pay:
                         (not specified) Up to 25% more Up to 50% more Up to twice as much More than twice as much

Would you be interested in having phone and data over one link/connection: Yes No
Select any of these payments you would be willing to pay for this: Would pay 25% more Would pay 50% more Would pay double

Would you like to receive further mailings on this matter to your address above: Yes No
    If yes, contact me at: (not specified) Personal address Business address

Would you be willing to work on this local telecommunications group: ??? Yes No