Dial-up Internet - CVC Internet, LLC

Dial-up Internet Sign-up Form

* Required Fields

[FrontPage Save Results Component]

* First Name

* Last Name

Company Name

* Street Address

* City

* State

* Zip Code

* Billing Address

* City (Billing)

* State
(Billing)

* Zip Code(Billing)

* Contact Number

Secondary Contact Number

Fax Number

* E-mail Address

* Type Of Service

Service Terms and Conditions

* Method Of Payment
First Month's Service Must Be Paid Before Service Is Activated.
Method of Payment Terms and Conditions

Credit Card Number

Name On Credit Card

Expiration Date

Pin Number

* Billing Notices
Billing Terms and Conditions

Forwarding E-mail Address
If you have an established e-mail account such as HotMail that you would
like your CVC Internet e-mail forwarded to, please enter the e-mail address above.

* Type of Setup

* User Name
User Name Instructions

*Password
Permission Instructions

*Computer In Use:

CPU: Pentium AMD Celeron

Processor Speed:
133-300 333-500 533-700 750-900 900 and above

Type of Operating System:
Windows
95/98 NT ME 2000 XP XP

Macintosh
Standard I-Mac

Type of System: Desktop Notebook
Browser:
Internet Explorer Netscape Other Program:

E-mail:
Outlook Express Outlook   Netscape Other Program:

Comment

Minor Consent Minor Consent Terms and Conditions
I agree to the Terms and Conditions for subscribers under 18 years of age.

I do not agree to the Terms and Conditions for subscribers under 18 years of age.

* Security Code:
To ensure the security of your form, please enter the security code (displayed below) in the text box. This code is an image that cannot be read by machines. It prevents automated programs from submitting fraudulent messages.

Terms of Service
By clicking the Submit button, you are agree to CVC Internet, LLC's Terms and Conditions of Service - Service Terms and Conditions. If you have any questions regarding service or terms of service, please contact CVC Internet, LLC at (541) 884-5488 or office@cvc.net before signing up for service.

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