Business: Request Fiber Internet Service

First Name *

Last Name *

Business Name *

Address *

Address

Mississippi

Address

United States

Cell Phone *

Home (Secondary) Phone

Email *

Monroe County EPA Account Number

Current electric service entrance to your business (Overhead or Underground)

Please Select How You Would Like to be Contacted: (Check All That Apply) *

Text Message

Email

Phone Cell

M-PULSE Fiber Internet options (Check only one) *

MEGA-PULSE 100 Mbps – $85.00

GIGA-PULSE 1 Gbps – $305.00

** Managed Wi-Fi Service Included in Above Prices **

Would You like to sign up for phone service from M-PULSE Fiber?

Yes

No

M-PULSE Phone options (Check only one)

Keep my existing Phone Number

Give me a New Phone Number

Phone Line Options (Check All That Apply)

First Phone Line – $34.95

Additional Phone Lines – $34.95 each (enter number in field)Additional Phone Lines – $34.95 each (enter number in field)

Existing Phone Number

Please Read and Check Where Applicable:

I AGREE TO RECEIVE AN E-BILL STATEMENT (VIA THE SAME EMAIL ADDRESS IN THIS FORM) AND NOT A PAPER BILL.

I WOULD LIKE TO SIGN UP FOR AUTOMATIC BANK DRAFT FOR M-PULSE FIBER USING THE SAME BANK ACCOUNT INFORMATION ALREADY BEING USED FOR MONROE COUNTY ELECTRIC POWER ASSOCIATION.

I AGREE TO SIGN UP FOR AUTOPAY USING BANK DRAFT. (SEE ATTACHED FORM)

Bank Draft Form

Must Agree to the Following *

I AGREE TO NOTIFY M-PULSE FIBER IF ANYONE IN THE RESIDENCE IS DIAGNOSED WITH COVID-19.

I CONFIRM I AM THE OWNER OF THE PROPERTY WHERE SERVICE IS BEING REQUESTED OR HAVE THE PERMISSION FROM THE PROPERTY OWNER.

I HAVE RECEIVED A COPY AND AGREE TO THE SERVICE APPLICATION/AGREEMENT WITH GENERAL TERMS AND CONDITIONS.

Terms and Conditions

M-Pulse Fiber LLC

Business: Request Fiber Internet Service

We will consider a submitted form as intent to start the installation process.