| Name: |
____________________________________ |
| Address |
____________________________________ |
| City: |
____________________________________ |
| State: |
Iowa |
| Zip: |
____________________________________ |
| Daytime Telephone |
____________________________________ |
| Fax Telephone: |
____________________________________ |
Billing Address
(if different)
|
____________________________________ |
| |
|
Preferred Username
(e-mail address): |
____________________________________ |
| |
(8Characters Max.) |
| Mother's Maiden Name |
____________________________________ |
| |
(Needed for password Security) |
| Package: |
System type: (Choose one) |
| [ ] Local calling area access $ 21.95/month |
Win 95 ____________________ |
| [ ] 6 Month Pre-pay at $19.95/month |
Win 98 ____________________ |
| (NOTE: up to 4 email address is included
with account) |
MAC ______________________ |
| |
iMAC _____________________ |
| [ ] Additional email address $10.00/month each |
WebTV ____________________ |
| [ ] DSL 128K $39.99/month |
Internet TV _________________ |
| [ ] DSL 256K $49.99/month |
Win ME ___________________ |
| |
Win XP ___________________ |
| |
Win 2000 ____________________ |
| |
|
| |
|
| |
|
| 1st additional email address username _________________ |
REAL name__________ |
| 2nd additional email address username _________________ |
REAL name__________ |
| |
|
Prices & Availability
subject to change without notice.
800 number access available through netINS.
|
| Customer Signature__________________________________ |
Date ____/______/______ |
| |
|
Please return this completed form to:
Advanced Network Communications,LLC |
Advanced Network Communications,LLC
111 West Second Street
P.O. Box 38
Schaller, Iowa 51053
FAX 712-275-4121
|
| |
|
| |
|
Authorized Telco Signature_________________________
|
Active date ______/______/__ |
