User sign-Up (Print form, complete, and return to US36.Net)

Date:

Account Name:

Company:

Contact:

or Name:

Telephone Numbers:

Work:

Home:

Fax:

Address:

Street:

City, State, Zip Code

User Set-Up Information: (3 characters minimum, 8 maximum / lower case)

1st choice of Username:

2nd choice of Username:

(3 characters minimum, 8 maximum / lower case)

Password:

Web TV Address:

Type of Account:

SetUp Fee

____Direct Payment (ACH Debit) ........................................ $10.00

____Annual, SemiAnnual, Quarterly or Monthly Payment ..... $20.00

Dial Up Account:

____Access One (75 Hours) .............................. $14.95 Per Month

____Access Two (150 Hours) ............................ $19.95 Per Month

____If more than 75 or 150 Hours used .................. $1.00 Per Hour

Add-ons:

____Extra E-Mail Addresses (Each) ....................................... $2.00