Internet Signup Form

Please provide the following contact information:

Name
Address
City
County
State
zip code
Home Phone
Did someone refer you over If you pay 3 months they get a free month

TECH ONLY: Pick a start date closes to todays date :

NONE 1st 15th 25th

Request a access number, Pick one.

            NONE 425 757 699

Please provide your account information:

User Name
2nd choice User Name
Password
Confirm  Password

First Months payment must be in to activate account, please choose how you are going to pay today or:
If you cannot pay today when will you be in, the account will not be activated till payment is in:

           NONE Cash Check Credit Card Debit Card

If it is a Credit / Debit Card
           NONE Mastercard Visa Discover Card American Express

Credit Card / Debit Card Number

Expiration Number

Amount To Be Run

FULL name on Card

If you are paying by CC or DB, Do you want $15.00 automatically withdrawn from your account each month for internet
YES NO

Do you need help with setup?

Yes No

What Operating System do you have?

winXp
win2000
winME
win98
win95
Linux
other

Who is setting up this person:
ONLINE SIGNUP Dustin Jon Rebecca

Tech Notes: