Dialup Form Print Sheet

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).

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