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This website information was revised on Wednesday, February 11, 2004 12:28:20 PM

 
 
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Internet Dial-up & Website Hosting order form

To better serve you, we use PayPal and ProPay for all you credit card transaction needs.  Services may be paid for by check, cashier's check, money transfer or credit card.

  Make payments with PayPal - it's fast, free and secure!   Process Credit Cards with ProPay 

Please provide us with as much information as you can.  If you are not a business, then you may leave the business fields blank.  All new accounts must be paid in advance.  

Full Name - REQUIRED
Company Name - IF APPLICABLE
Billing Address -  REQUIRED
Mailing Address - REQUIRED
City - REQUIRED
State - REQUIRED
Zip Code - REQUIRED
Work Phone number - IF APPLICABLE
Home Phone number - REQUIRED
Current Email Address - REQUIRED
Website URL - IF APPLICABLE

Please check the type of service your would like to receive
Dial-up Access service only
Dial-up Access with email service
Website hosting service only
Dial-up and Website hosting service

How would you like to pay for your services?
Please choose an option
Pay Pal    Pro Pay  Credit Card
Credit Card payments may be made by ProPay or by telephone.

All service requests will receive a reply within 2 hours.
Your preference of contact - Phone    E-mail
(Please make one selection)
Preferred time to contact -

Notes/Comments - 

 

 

 
 
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