Internet Account Sign-up Request Form

Email Address:
Mailing Address:
City, State, Zip:
Physical Address:
City, State, Zip:
Home Phone:
Cell Phone:

User Name:
(3 - 8 Characters)
(6 - 10 Characters)
Your email address will be:
DSL Packages:
If you selected a "Bundled" Internet package, complete the Telephone Account Sign-up Request Form
DSL Modem:Info here
Content Filtering:
Plan Upgrades:Info here

Computer Type

Installation Time

Requested Install Date:

Requested Install Time:


LightBurst Broadband is pleased to offer free technical support for your initial Internet connection installation. Technical support for other Internet, hardware, software or computer virus problems is available from our Technical Support staff at reasonable prices. Please see the complete list of available services at (Computer Services).

By signing this Internet Account Sign-up agreement, I acknowledge that I have read, understand and agree to abide by the LightBurst Broadband Internet Services Acceptable Use Policy as defined on the LightBurst Broadband webpage at I understand that my account may be terminated without refund for failure to abide by these rules and regulations. I also acknowledge that I have read and understand the LightBurst Broadband Open Internet Transparency Statement as defined on the LightBurst Broadband webpage at

I certify that I am over 21 years of age and agree that I alone am responsible for the use or misuse of my account, and that I am responsible for payment of the LightBurst Broadband Internet service at my location. Bills are due and payable within 10 days of the billing date.

Comments or Questions:
(1000 Character Limit)
Digital Signature: Date:
  A LightBurst Broadband representative will contact you to verify service request information and set an installation time. LightBurst Broadband requires that each customer provides a signed Internet Account Sign-up form. If you sign up for service via the Internet, the form will be provided to you by the Installation Technician during the installation.