DIAL-UP ACCESS

__________________________________________________________________

Application for Dial-Up Access 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:

How did you learn of PatriotNet?
If referred, by whom?

Service Desired

Service:

Username:

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:

Add Alias?

Yes, add an email alias to this account for $10. An email alias causes email addressed to the alias you specify, such as jonathan.doe@patriot.net, to be delivered to the email box for this account (by linking the alias to the username above, such as "jdoe"). Check here to request that we assign this account 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 (unlike username, the alias can be more than 8 characters, and can contain special characters such as "." and "_"):
Email Alias:

Operating system:

If "other", please specify:

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 PO Box 1846 Herndon, VA 20172

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: