First Name Last Name Street Address State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Email Address Phone Number Best way to reach you - None -PhoneEmail Days/Times that work for you Which CapTel Phone Model do you have? - None -CapTel 840CapTel 840iCapTel 880i Do you have an analog telephone line? Yes No If you have DSL, is the DSL filter in place? Yes No Do you have a VoIP, FiOS, Digital cable service or DSL with filter? Yes No Do you have High Speed Internet or Broadband cable to the internet connection via a modem or router? Yes No Do you have a router? Yes No Do you have a modem? Yes No Comments Please note: If you are using a wireless router or WiFi, you do not need a high speed cable.