This form is for pre-subscription / site survey for your home or office for Wire Free Nebraska Service only. This is not an order placement. Not all homes or offices qualify for Wire Free Nebraska installation.  Upon receipt of this material, a form will be mailed to you.  It will become a subscription agreement only if a Wire Free Nebraska tower is accessible from your computer location or a point on your property  within 250 feet of your computer location.  Upon return of the form a site surveyor will be dispatched to confirm your location qualifies.

I am interested in the	Please select residential DCL basic business DCL package.
First Name:
Last Name:
Address:
City:
State:
Zip/Postal Code:
Phone Number:
Alt Phone Number:
Best time to contact:	Please select Before Noon Between Noon and 6:00 PM After 6:00 PM
E-mail:
Purchase Equipment?	Please select Yes No Maybe
Directions/Notes: (Directions to your location. Please indicate landmarks and verbal description to assist in your site survey)

If you are an existing Megavision subscriber, please provide your user ID:

User ID

@megavision.com