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[photo: Residential Dial-up]
Residential Dial-up

56k Dial-up Order Form

* required information
CUSTOMER INFO
* First Name:
* Last Name:
* Daytime Contact Phone Number:
E-Mail Address:
Who Referred You?:
(enter their email address)
*Dial-up Service Address:

* City:
* State:
* Zipcode:

TECHNICAL INFO
* Desired Dial-up Service:
* Desired Dial-up Billing:
* Computer Operating System:
Do you want content filtering?
(residential customers only)
  What is content filtering?
Yes - $4.00/month
No
* Desired Primary Email: @
Alternate Primary Email: @
Desired Secondary Email: @
Alternate Secondary Email: @

OPTIONAL INFO
Special Code
(optional)

(i.e. Discount, Partner, or Referral Code.)
Comments: