Midcoast Internet Solutions

Residential Internet Phone Service
Inquiry/Order Form

To proceed with the service ordering, please fill out the fields below and someone will contact you to schedule the service installation.

	Existing Number to move (xxx-xxxx)
Service Address
Street Address:
City
Zip:
Billing Address
First Name:
Last Name:
Street Address:
City
Zip:
Standard Options	Voice Mail, Call Forwarding, 3-way Calling, Caller ID with Name. See MIS for non-standard options.
3rd Party Billing Block:	Yes No
Collect Call Block:	Yes No
Call waiting w/ Caller ID:	Yes No *Does not work with Voice mail or Call Forwarding
International Call Block:	Yes No
Intrastate Block:	Yes No
Interstate Block:	Yes No
Caller ID shall display:	(Up to 15 characters)
Contact Phone Number:
Current Email Address:
Current MIS broadband customer?:	Yes No
Equipment Choice

Notes:

594-8277
25 Oak Street
Rockland
Contact
Midcoast Internet Solutions
563-8563
134B Back Meadow Rd.
Nobleboro