Please Print this page, fill out the information and fax it to RGV-Net @ 1-956-618-1982



Customer Name : ________________________________

If Business, Business Name : ____________________________________

Address, City, State, Zip-Code : ________________________________________________________________

If Residential, Contact Name : ___________________________________

Address, City, State, Zip-Code : _________________________________________________________________

Phone # : Business : _________________________

Residential: _________________________



Type of DSL Desired : ________________________

Tpye of Modem Desired : ______________________

Your Current ISP : ____________________________

Your Current Access Type : ____________________

Your Current E-mail Address : ________________________________


Thank-You for your interest in DSL with RGV-Net