LOCAL INTERNET ACCESS CUSTOMER ENROLLMENT FORM

Business Acct: Company Name________________________ Contact Name________________________

Personal Acct: Last Name_____________________ First Name___________________ M.I.____________

Address:_____________________________________________________________________________________

City:___________________________ State:_______________ Zip:_________________

Date Of Birth:______________ Subscribers certify that they are at least 21. Refer to "Acceptable Use Policy."

Home Phone: (_______) - ________ - ___________ Work Phone: (_______) - ________ - __________

E-Mail Address (Login Name):___________________________________________

All login names must be lower case, only letters and numbers and 4 to 8 characters.

Desired Password:_____________________ Mother's Maiden Name:___________________

Invoice: 3 Months $60        Invoice: 6 Months $120       Invoice: 1 Year $200

All $20 monthly payments are a credit/debit card transaction. The credit/debit card is billed initially on your start date. Monthly billing is done the first business day of every month.

Acceptable cards are Visa, MasterCard, American Express or Discover.

Card Type:_______________________ Card No:___________________________________________

Cardmember Name:______________________________________ Expiration Date:___________________

Customer Signiture (Required):______________________________________________________

For Office Use Only___________________________________________________________________

UserID#______________S/N____________________Enrollment Date:____________V.A.030101-web