Click Here to print & fill out the Dialup Request Form:
Your Full Name: _________________________________
Phone Number: _________________________________
Physical Address: _________________________________
City, State & Zip: _________________________________
Dialup & Email User Name: ________________________________________________ @icsisp.com
Dialup & Email Password: _________________________________ (Minimum of 5 Characters)
Today's Date: _________________________________
Billing/Dialup Start Date: _________________________________ (NOTE: OFFICE USE ONLY)
Computer Type: _________________________________ (Example: Desktop or Laptop)
Operating System: _________________________________ (Example: Windows 98, ME or XP)
Billing Method: _________________________________ (Example: EMAIL, CASH, CHECK, VISA, MASTER or DISCOVER)
Billing EMAIL Address: ____________________________________________________________
Terms & Service Agreement: YES or NO (Please mark Yes or No - This is the agreement for the Terms Below)
Installation Type: Self Install (Free with Instructions) or ICSISP Install ($64/Hr - 1 PC Only)*
*Note: For install of multiply PC's requires extra hardware - Wired or Wireless Router/WAP (Wireless Access Point). Call for further details.
Do you need additional Email Accounts: YES or NO (Please mark Yes or No)
How many additional Email Accounts: _________________________________ (Please write 4 if you only want the 4 extra free accounts, if you need more write down how many so we know the monthly charge per email account, which is $1 each account per month).
webmaster@icsisp.com