Internet Account Application
________________________________________________________________________________________________
office use only
Entered on Server: _____________ Reference
#:__________________
Check #_____ Cash____ CC_____
Amount:_____________________
________________________________________________________________________________________________
Tech Support: 258-HELP or 877-994-8355
Mon - Fri: 8:00 AM - 5:00 PM
Dial Up Numbers:
Cutler, Frankfort, Michigantown: 258-5600
Burlington, Rossville: 258-5600
Bringhurst, Delphi, Flora: 268-2525
Name:________________________________________________________________________
Address:______________________________________________________________________
City:___________________________________ State:________ Zip:______________________
Telephone Number:_____________________________________________________________
Mother’s Maiden Name:__________________________________________________________
Choose an EMAIL name up to 8 characters, all lower case: ___ ___ ___ ___ ___ ___ ___ ___
Choose a PASSWORD up to 8 characters, all lower case: ___ ___ ___ ___ ___ ___ ___ ___
DSL
____ Bronze $29.95/month
256 Kbps download / 128 Kbps upload
____ Silver
$39.95/month 1.5 Mbps download / 384 Kbps upload
____ Gold
$49.95/month 3.0 Mbps download / 768 Kbps upload
____ Platinum $59.95/month
5.0 Mbps download / 1.0 Mbps upload
____ Diamond
$79.95/month 8.0 Mbps download / 1.0 Mbps upload
Wireless
____ Bronze
$29.95/month 832 Kbps download / 256 Kbps upload
____ Silver
$39.95/month 1.5 Mbps download / 384 Kbps upload
____ Gold
$49.95/month 3.0 Mbps download / 768 Kbps upload
____ Platinum $59.95/month
5.0 Mbps download / 1.0 Mbps upload
* All connection speeds listed are maximum connection speeds, network conditions may effect connection speeds.
Dial Up
____ Starter Package
$14.95/month
____ Unlimited Package
$18.95/month
____ 1 Year Package
$160.00 non-refundable after 30 days
Bill Me Monthly ____________
Charge my Credit/Debit Card Monthly _____________ - charges to card will be made on the 17th of each month
VISA MC DISCOVER Account# ________________________________________________Exp. Date______
I hereby certify that the above information is correct, that I have
read the Acceptable Use Policy on the
back and that I agree to use the Internet in a legal, ethical, and
positive manner.
SIGNATURE: _____________________________________________________Date: ___________________
Monthly Internet usage is calculated beginning on the 1st of each month at 1:00 a.m. Unlimited access is defined as 744 hours, which is equal to 24 hours, 31 days a month. There will be a $35.00 trip charge for any in-home Internet setup during normal business hours and $45.00 charge outside of normal business hours. Normal business hours are defined as Mon-Fri: 8:00 AM - 5:00 PM.