Email Sign Up Form for Purespeed Internet Service

Customer Information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Please select a username and password.  The User Name you select will also be your initial email address.

User Name	@purespeed.com
Password
Confirm Password

Choose one of the following options:

Monthly at $17.95
Annually at $167.40 ($13.95 per month)
Two-Years at $300.00 ($12.50 per month)
Six Months at $97.70 ($16.28 per month)
Three Months at $49.95 ($16.65)

Payment Options:

For Payment via Credit Card, complete this section.

	Credit Card Information
Credit Card	VISA MasterCard American Express Diner's Club Discover
Cardholder Name
Card Number
Expiration Date

Contact Me for My Credit Card Information

For Payment Options Other Than a Credit Card.

Pay by Check Pay by Electronic Funds Transfer Pay by E-Check Pay by Bank Draft Pay by Other Method

Additional Options:

As a Purespeed subscriber, you receive four (4) email accounts, would you like Additional Email Accounts?

Yes No

Do You Wish to Establish a Personal Web Page?

Yes No

Please Contact Me About My New Account:

Call me at Home
Call me at Work
Contact Me via Email
Send me a Letter
Send me a Fax

I Want My Service to Start On:

-- mm/dd/yy

Any Additional Information You Wish to Tell Us?