Name:
|
____________________________________ |
| Address: |
| ____________________________________ |
| ____________________________________ |
| ____________________________________ |
|
| Billing Address: |
| ____________________________________ |
| ____________________________________ |
| ____________________________________ |
|
| Telephone: |
____________________________________ |
| Alternate Telephone: |
____________________________________ |
| Service: |
| Dial Up: |
Basic $18.95 per month |
_______ |
| |
Accelerated $19.95 per month |
_______ |
| |
Premium $24.95 per month |
_______ |
| DSL: |
|
|
| 64K/128K |
$29.95 per month |
_______ |
| 128K/256K |
$39.95 per month |
_______ |
| 256K/512K $49.95 per month |
_______ |
| Modem Rental/ Insurance $5.00 per month |
_______ |
| Modem Purchase $99.00 |
_______ |
| Installation $100.00 |
|
| (may be waived with 12 month contract) |
|
| WiFi (Bellevue only) $40.00 per month |
_______ |
| Installation $200.00 |
_______ |
| (may be waived with 12 month contract) |
|
| |
|
|
| Secure IT $7.00 per month |
_______ |
| |
|
|
|
| Desired Username (for email address): _______________________@netins.net |
