Please fill out the Residential DSL Request Form:

Your Full Name:
Contact Phone Number:
DSL Phone Number:
Physical Address:
City, State & Zip:
EMAIL User Name:
DSL & EMAIL Password: (Minimum of 5 Characters)
Today's Date:
Computer Type: (Example: Desktop or Laptop)
Operating System: (Example: MAC, Linux, Windows 98, ME or XP)
How Many Phones Do you have Plugged in?:
Billing Method: (Example: EMAIL, CHECK, VISA, MASTER or DISCOVER)
Billing EMAIL Address:
Installation Type: Self Install (Free with Instructions) or ICSISP Install ($64/Hr - 1 PC Only)*
*Note: For install of multiply PC's requires extra hardware - Wired or Wireless Router/WAP (Wireless Access Point). Call for further details.
Do You Need Extra Email Accounts?:
How Many Extra Email Accounts?:
Terms & Service Agreement: (Please Type Yes or No if you agree to the staement below)
  • AT&T must be the provider of your local telephone service. One-year term required. Cancellation before the end of the one-year term is subject to an early termination fee equaling to the balance of the remaining monthly contract charges, which ever is less. At the end of the initial term, then-current rates will apply for continued service.
  • $64 additional charge if a ICSISP Technician performs installation. Installation covers connecting a single PC to the DSL modem. Any additional installation work required or requested will be billed at $64 per hour. The equipment charge will appear on the first bill along with any corresponding and offsetting credits.
  • Service may not be available in all areas. Subject to change without notice. Actual downstream and upstream throughput speeds will vary. The downstream and upstream access speed or sync rate is measured between network interface device at customer's location and the DSL-equipped Central Office or Remote Terminal. The actual speed achieved will depend on several factors, including line conditions and loop length. Equipment is a new or fully inspected, tested and warranted return unit.
  • Billing begins on service activation date. Acceptance of Terms of Service required. Taxes are included in the monthly fees. Other restrictions apply.
  • If customer moves and the new telephone number is NOT capable of receiving DSL service from ICSISP, the termination fee will be waived. Installation charges will apply if a ICSISP technician is required or requested to perform installation due to a customer move.
  • You must give ICSISP 30 days notice for cancelation.

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