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Home phone survey

* - required field

* First Name:	* Last Name:
* Contact phone: --	* Email:
* Your current phone provider:	* Your current long distance provider:
* Number of lines:	* Do you have internet: yes no
* Local calls monthly bill:	* Long distance average monthly bill:
* How did you hear about us?:

Winner will be contacted at the end of each month via phone number
provided in the survey.