| 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) |
| Internet ~ Monthly |
System type: (Choose one) |
| __________421-Service Unlimited |
$25.00 |
Win 95 ____________________ |
| __________716-Internet Install |
$15.00 |
Win 98 ____________________ |
| |
MAC ______________________ |
| Internet ~ Services |
iMAC _____________________ |
| __________Dial Up |
$24.95 |
WebTV ____________________ |
| __________256 High Speed Internet |
$ |
Internet TV _________________ |
| __________512 High Speed Internet |
$ |
Win ME ___________________ |
| __________1024 High Speed Internet |
$ |
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: |
Interstate Communications
105 N. West Street, PO Box 229
Truro, IA 50257
Phone: (641) 765-4201
Fax: (641) 765-4204
|
| |
|
| |
|
| Authorized Telco Signature______________________________ |
Active date ______/______/__ |
