World Access Communications

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World Access Communications, Inc.
1209 W. Tokay St.
Suite #11
Lodi, CA 95240
866-DIAL-WAC (342-5922)
info@corp.wac.com

DSL Sign-Up Form
"*" denotes a required form field.

PERSONAL INFORMATION
*Name:
Company:
*Address: (at installation location)
*City:
*State:
*Zip:
*E-mail Address:
*Contact Telephone:
*Telephone: (at installation location)
Fax Number:
SYSTEM INFORMATION
*Primary Location Focus:	Business Residential
Equipment Needed:
Connection Speed Desired?
Need a Router? (For more than one computer)	Yes No
If Yes, Please Specify:
How did you find us?
Note: If you selected "other" please indicate the person or collateral responsible for your referral