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Request Form

Request for Cable TV, MaxxSpeed Internet and Home Phone

Community Name


MaxxPartner Sales ID

MaxxPartner Email

MaxxPartner Phone Number

Resident Information

Please enter the information of the resident who is moving into your apartment community.

Resident's Name

Resident's Address

Cell Phone

Resident's Email

The new resident is interested in the following MaxxSouth Broadband services (check all that apply):

Cable TV
MaxxSpeed Internet
Home Phone

Special Notes or Instructions

MaxxSouth Broadband is herein authorized to provide my contact information to an Authorized Employee of MaxxSouth Broadband, 105 Allison Cove, Oxford, MS 38655 (“MaxxSouth”). I understand that the information is to be used for the purpose of MaxxSouth contacting me to improve service opportunities and provide details regarding its current marketing promotions available; however, MaxxSouth is in no case required to provide such follow-up or information. By signing below, I/we understand that my information as outlined above will be provided to MaxxSouth, for the purposes outlined herein. This authorization terminates one year from the date of this Letter of Authorization, or earlier if I/we provide written revocation to.

I agree