Name:
Date:  
Address:
City:
State:
Zip Code:
Telephone #:

Operating System:
Windows 3.1
Windows 95
Windows 98
Windows NT
Other:

User Name:
Password:  

Would You like extra E-mail accounts ($2 per box)? Yes No
If yes, how many?

Extra Email accounts:

Name:
User Name:
Password: 

Name:
User Name:
Password: 

Charges:
Number of Months:
Extra email $2.00 each:
Total: