Interest Form - Platinum Connect

Which type of service are you interested in?

Residential

Business

Thank you for your interest in Platinum Connect. Please complete the form below to sign up for fiber optics.

Help bring Platinum Connect's reliable FIBER connection and services to your business by completing this form. After reviewing your submission one of our Commercial Account Reps will reach out to plan your installation.

Customer Information

First Name *

Last Name *

Business Name

Email *

Primary Phone *

Primary Phone Type *

Cellular

Landline

Secondary Phone

Secondary Phone Type

Cellular

Landline

What type of business?

Number of employees

Service Address

Street Address *

City *

State *

Zip *

Mailing Address

Is your Mailing Address different than your Service Address? *

Yes

No

Mailing Address *

Mailing City *

Mailing State *

Mailing Zip *

Home Ownership Information

Do you own or rent the location you would like a fiber connection? *

Own

Rent

Landlord First Name *

Landlord Last Name *

Landlord Contact Email

Landlord Contact Phone *

Interested Services

Which Platinum Connect services are you interested in? *

High Speed Internet

Digital TV

Digital Voice

Phone Systems or Hosted Voice Services

Who is your current internet provider?

Who is your current phone provider?

Who is your current TV provider?

Who can we thank for referring you to us?

How did you hear about us? *

Community Event Name? *

Platinum Connect Employee Name? *

Friend or Neighbor Name?

Other

Do you have any questions that our team can answer for you?

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