Internet Registration
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Internet |
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Marne Elk Horn Telephone 4242 Main Street * P. O. Box 120 * Elk Horn, Iowa 5153 Phone: 712-764-6161 * Fax: 712-764-2773 |
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NAME:
_______________________________________________________________ (Please print or type) BUSINESS:
___________________________________________________________ ADDRESS:
____________________________________________________________ CITY:
______________________________
STATE: ______
ZIP: _____________ HOME
PHONE: ( )_____-_________
DAYTIME PHONE: (
) _____-_________ BILLING ADDRESS IF DIFFERENT
_______________________________________ PLEASE
INDICATE SYSTEM TYPE: ( )Windows 95
( )Windows 98 ( )Windows
ME (
)Windows 2000 (
) Monthly
Internet Access Charge
$19.95 / month 1 PRIMARY E-MAIL
ADDRESS PLUS 4 ADDITIONAL ADDRESSES ARE INCLUDED
NO SET-UP FEE FOR A
LIMITED TIME PRICES
& AVAILABILITY SUBJECT TO CHANGE WITHOUT NOTICE. CLICK
HERE FOR TERMS & CONDITIONS CUSTOMER SIGNATURE ________________________________________DATE _____________ AUTHORIZED TELCO SIGNATURE ________________________________DATE ________________ FOR
OFFICE USE ONLY: ACCOUNT NUMBER
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