1a. Your First Name:		(Required)
1b. Your Last Name:		(Required)
2. Organization:
3. Your Current Provider:		(Required)
4. Interested in obtaining service (please check one or more):		(Required)
	Home Business Internet Service Company (ISP/Telco)
5. Please check the region(s) where you are located or where your organization is interested in obtaining service (please check the segment your community is located between):		(Required)
	Southern Corridor
	Monroe to Adrian Adrian to Hillsdale Hillsdale to Coldwater Coldwater to Three Rivers Three Rivers to Dowagiac Dowagiac to Berrien Springs Berrien Springs to Benton Harbor
	Western Corridor
	Benton Harbor to Zeeland Zeeland to Muskegon Muskegon to Ludington Ludington to Luther Ludington to Manistee Manistee to Beulah Beulah to Traverse City Traverse City to Kalkaska Kalkaska to Charlevoix Charlevoix to Petoskey Petoskey to Mackinaw City
	Central Corridor
	Mt. Pleasant to Clare Clare to Gladwin Gladwin to Houghton Lake Houghton Lake and Grayling Grayling to Gaylord Gaylord to Hillman
	Eastern Corridor
	Midland to Bay City Bay City to Tawas City Tawas City to Oscoda
	Northeast Corridor
	Oscoda to Alpena Alpena to Rogers City Rogers City to Indian River Indian River to Cheboygan Cheboygan to Mackinaw City Indian River to Gaylord
	Middle Corridor
	Grand Rapids to Big Rapids Big Rapids to Le Roy Le Roy to Cadillac Cadillac to Oscoda Le Roy to Luther Rose City to Grayling Grayling to Kalkaska
	North Corridor
	Mackinaw Bridge to Escanaba Escanaba to Powers Powers to Iron Mountain Iron Mountain to Iron River Iron River to Watersmeet Watersmeet to Ironwood Ironwood to Duluth Watersmeet to Houghton Houghton to Calumet Ontonagon to Rockland Powers to Wallace Wallace to Menominee Menominee to Green Bay
Contact Information
6a. Street Address:		(Required)
6b. City:		(Required)
6c. Zip Code:		(Required)
Method of Contact
7a. E-mail Address:		(Required)
7b. Phone:		(Required)
7c. Fax:
Comments
8. Your Comments: