High-Speed Internet Request Form
Thank you for your interest in the 4GAS.ONLINE Rural America internet program. This form is used to gather basic information so we may qualify your address for internet services in your area. You may also call us at 850.449.8888 after you complete your request. We are open M-F 830AM-8PM and Sat/Sun 830A-5P
* Required to complete application.
Please provide the primary address you intend to use the internet service at. Shipping address if different can be provided in the notes section.
District of Columbia
Other (Explain in notes)
Your contact number:
Please provide us your best contact number that we can reach out to you with more information within the next 24-48 hours. We will attempt to contact you and if we are not unsuccessful in contacting you, your application will be placed in a do not disturb status.
Proof of business:
Please attach proof of your business, such as business license or Federal EIN Application. Contact us at (815)496-0444 for more information regarding this requirement.
Service and coverage statement.
Coverage is not available in all areas. The 4G Antenna Shop Inc. does not guarantee service will work in your area. Your sales consultant will double check your area for coverage and technology in your initial setup call.
Which Internet device are you interested in?
4GAS Home Modem
4GAS USB Stick Modem
FREE SIM Card - I have my own modem. $0
Please provide any additional information regarding your application.
Add any special information such as shipping or rate plan instructions.
By submitting this application form you agree that you have reviewed the information provided on this site and are in full understanding of the terms, policies and procedures of the 4G Antenna Shop Inc. and you allow 4GAS Online to continue with the application process on your behalf.
Today's date: (Application Date)
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