DSL Residnetial 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)

How Many Phones Do you have Plugged in?: _________________________________ (Note: This is for Filters)

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, unless you own a domain they are all free).

  • AT&T must be the provider of your local telephone service. One-year term required. Cancellation before the end of the one-year term is subject to an early termination fee equaling to the balance of the remaining monthly contract charges. At the end of the initial term, then-current rates will apply for continued service.
  • $64 additional charge if a ICSISP Technician performs installation. Installation covers connecting a single PC to the DSL modem. Any additional installation work required or requested will be billed at $64 per hour. The equipment charge will appear on the first bill along with any corresponding and offsetting credits.
  • Service may not be available in all areas. Subject to change without notice. Actual downstream and upstream throughput speeds will vary. The downstream and upstream access speed or sync rate is measured between network interface device at customer's location and the DSL-equipped Central Office or Remote Terminal. The actual speed achieved will depend on several factors, including line conditions and loop length. Equipment is a new or fully inspected, tested and warranted return unit.
  • Billing begins on service activation date. Acceptance of Terms of Service required. Taxes are included in the monthly fees. Other restrictions apply.
  • If customer moves and the new telephone number is NOT capable of receiving DSL service from ICSISP, the fees left on the bill must be paid after the circuit is canceled. Installation charges will apply if a ICSISP technician is required or requested to perform installation due to a customer move.
  • Additional email accounts are $1/each if you request for more than 4 with the current DSL Email account. The only exception to this is that you own your own domain and can have as many email accounts as you need.
  • You must give ICSISP 30 days notice for cancelation.

Applicable to Dynamic Products
Laptop users and some desktop users may need to purchase an Ethernet card.

Mail To or Drop off this sheet at:
Image Computer Soltuions (DSL)
44 North 4th Street
Zanesville, OH 43701
© Copyright 2008