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: 

Name:
User Name: Password: 

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: