Quality Assurance Survey Will you be utilizing the video service for personal or business? What is your email address? What is your full name? What is your phone number? Who will you be communicating with via the video service? What 7-digit phone number would you like to reuse as your video number? This must be a valid number like your home, office or cell number. What would you like to register as your caller ID (up to 16 characters)? Do you have a computer connected to the internet? Yes No Do you have high speed internet access? Yes No What broadband internet service do you currently have installed? DSL or Cable Modem What is the distance between your cable or DSL modem and the TV you would like to connect our set top box? Do you have a wired or wireless router with a computer network currently installed? Yes No If so, what is the manufacturer and model number of your wired or wireless router ? Would you like information on our wireless package? Yes No Would you like to add our wireless package to your video communications service? Yes No

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