Name: Date: Address: City: State: Zip Code: Telephone #:
Operating System: Windows 3.1,Windows 95 ,Windows 98 ,Windows NT Windows 2000,Windows 2001,Windows XP 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:
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Charges:
Setup fee $10.00 (waived when you sign up for 3 months) Monthly service $17.95 Number of Months: Extra email $2.00 each: Total:
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