Sales Info Gathering Rev Contact to Plat Sales New Customer DataTo be used between 7/14/22 - 7/31/22. This form will send the same information into both Platypus & Rev.io ticketing systems. Notification to(Required) Platypus Rev.io copy to me My Email(Required) Name(Required) First Last Service Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address ownership(Required) owns rents ownership not verified Phone(Required)Email Service Type Fiber Wireless Phone Package Cost & Speed(Required) RES Fiber $49.99 200M/200M (Dayton Only) $59.99 500M/100M $69.99 1G/200M $99.99 1G/1G CURRENTLY UNAVAILABLE Add-ons $10.00 Wifi Extender $10.00 Static IP RES Wireless $79.99 10M/5M (install $99.00) $99.99 20M/5M (install $99.00) $119.99 30M/5M (install $99.00) Add-ons $10.00 Wifi Extender $10.00 Static IP Digital Phone $20.00 RES Digital Phone Telephone Number(s) Existing Telephone Numbers Brand New Telephone Numbers Existing & New Numbers ordered Install(Required) Router Router Included Auto-pay Auto-pay OK Auto-pay not ok Other Notes