EMAIL SERVICE APPLICATION

__________________________________________________________________

Application for Email Service

Contact Information

Name:
Address:
City:	State:	Zip code:
Billing Contact, if different from Contact Name above:
Billing Address, if different from address above:
Billing Address City:	State:	Zip code:

Day phone:	Evening phone:
Fax:	Other e-mail:

Service Desired

Service:

Username for new account:

Please choose a username between three (3) and eight (8) characters in length, containing only numbers and lower-case letters, and beginning with a letter.

Your e-mail address will be of the form, username@patriot.net, where username is the username you choose.

First choice

Second choice

Email Alias?

Yes, create an email alias for $10. An email alias causes email addressed to the alias you specify, such as jonathan.doe@patriot.net, to be delivered to a specified email box (by linking the alias to another email address, such as "jdoe@patriot.net"). Check here to request that we create an email alias, for an additional $10 one-time fee. (If in doubt, leave this box unchecked; you can always add an alias later if you need one!) If yes, please specify the alias below, and the destination email address to which email addressed to the alias should be sent. Unlike username, the alias can be more than 8 characters, and can contain special characters such as "." and "_":

Email Alias:
(This is the email address you wish to redirect)

Alias Destination:
(Email address to which the alias should point)

Comments:

Payment Choice

Cash

Cash payments must be made in-person at the PatriotNet offices. Payment must be received before services will be activated.

Check

Payments by check must be mailed or made in-person at the PatriotNet offices. Checks should be made payable to PatriotNet. Payment must be received before services will be activated.
PatriotNet 9990 Fairfax Blvd, Suite 500 Fairfax, VA 22030

Credit Card

Card:
Name on card:
Card Number:	Expiration:

	Charge this card automatically at the start of each new term.
	Mail me a bill before the start of each new term.

Cardholder Address

If the cardholder's address is different from the address given in the Contact Information section, above, please supply the cardholder's address below.

Address:
City:	State:	Zip code: