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 you for internet services in your area. 4GAS.ONLINE is an authorized resale partner for several carriers and will attempt to confirm your address for the best service plan available. After submission of your information our representative will contact you promptly. You may also call us at 815.205.3300 after you complete your application so we can expedite processing and handling your order. We are open M-F 830AM-8PM and Sat/Sun 830A-5P or by email to email@example.com. Thank you for your interest and welcome to a new way to do internet.
4G Antenna Shop Inc.
* 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.
Required for business applications.
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.
Did a team memebr help you on the phone first?
Please let us know which team member helped you on the phone so we can assign that person to your application so they can continue to help you.
RV3 (Robert V)
TW (Teresa W)
NA (No one helped me)
MM (Monika M)
JM (Joey M)
DB (Donovan B)
YF (Yanira F)
MG (Michael G)
SB (Sierra B)
JC (Jazmine C)
SP (Sanjay P)
AR (Angela R)
GS (Giovanni S)
MV (Manuela V)
Would you be interested in enhancing your signal with an outdoor mounted antenna?
Adding an outdoor antenna enhances signal reception to your modem by eliminating everyday inside the house inferences caused by other electronics in the home or business: Pricing for an outdoor antenna is as low as $39.99 one time purchase and can make a big difference in service quality.
No outdoor antenna is needed at this time.
Yes please add an outdoor antenna to my order.
Which modem product would you be interested in?
4GAS Home Office Modem
4GAS Portable Hotspot Modem
FREE SIM Card - I have my own modem.
4GAS uses both USPS and UPS to ship your modem/antenna products to you, If you are just purchasing a MODEM from 4GAS the normal shipping charge is $8 Flat rate and is shipped by USPS (Post Office), if you are purchasing an Antenna Kit along with your modem, Shipping is FLAT Rate at $25 and is sent by UPS. You will receive a tracking number once your package has shipped.
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.
Confirm and complete your application.
By submitting an application for service with the 4G Antenna Shop Inc. you agree to terms set forth on this website. Furthermore you confirm that you are authorized to obtain services from the 4G Antenna Shop Inc. and meet the minimum required guidelines for service with the 4G Antenna Shop Inc.. If you are unsure of the requirements please visit the following links below for more information:
Rate Plans Q&A
Return Information and Conditions of Sale
4G Antenna Shop Inc. Authorized Re-seller Program
Please provide any additional information regarding your application.
Add any special information such as shipping or rate plan instructions.
Complete your application
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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