New subscriber Contact Info Name Email Phone Preferred Notification Method Mobile phone Mobile SMS Residence Address City Zip Code State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Time Zone Eastern Time Eastern Time - Michigan - most locations Eastern Time - Kentucky - Louisville area Eastern Time - Kentucky - Wayne County Eastern Time - Indiana - most locations Eastern Time - Indiana - Daviess, Dubois, Knox & Martin Counties Eastern Time - Indiana - Pulaski County Eastern Time - Indiana - Crawford County Eastern Time - Indiana - Pike County Eastern Time - Indiana - Switzerland County Central Time Central Time - Indiana - Perry County Central Time - Indiana - Starke County Central Time - Michigan - Dickinson, Gogebic, Iron & Menominee Counties Central Time - North Dakota - Oliver County Central Time - North Dakota - Morton County (except Mandan area) Central Time - North Dakota - Mercer County Mountain Time Mountain Time - south Idaho & east Oregon Mountain Standard Time - Arizona (except Navajo) Pacific Time Alaska Time Alaska Time - Alaska panhandle Alaska Time - southeast Alaska panhandle Alaska Time - Alaska panhandle neck Alaska Time - west Alaska Aleutian Islands Metlakatla Time - Annette Island Hawaii Broadband Provider Name Blue Ridge Cable ONE Charter Comcast Cox Direct to Consumer Mediacom Patriot Suddenlink Trial West River Windstream Broadband Provider Account Gateway Port Do you have an available port on your modem? Yes Residence Type apartment single-family dwelling assisted living other Size of residence Sq Ft Emergency Services Local Police Phone Number Local Sheriff Phone Number Subscriber How many people live with subscriber? 0 1 2 3 4 Birth year of subscriber? 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Does anyone make regular visits to the subscriber? Yes Does someone live within 15-minute driving distance of subscriber? Yes Is the subscriber capable of answering the phone? Yes Does the subscriber use an assistive device to walk? Yes Is the subscriber wheelchair bound? Yes Is the subscriber bed bound? Yes Does the subscriber have a history of falls? Yes Is the subscriber capable of reading and following simple instructions? Yes Is the subscriber capable of taking medication as directed? Yes Is the subscriber capable of leaving their home on their own? Yes Installation Desired Installation Date Preferred hours? Morning Afternoon Evening Submit or Exit
