ECHOWEB Personal Account Application

P.O. Box 53
Grants Pass, OR 97528
www.echoweb.net
info@echoweb.net

phone: 541-471-0457
fax: 541-471-0530
toll free: 1-888-471-0457
(from outside local calling area)

PERSONAL ACCOUNT APPLICATION To start a personal Internet account with EchoWeb, just fill out the application below and either mail it
to us at the address above, or drop it by:
EchoWeb , 543 NE 'E' St.,
Suite #106, Grants Pass
Date of Application: _________________________ [Rec'd: _________________________]

Username Requested: ____________________ Password: ____________________
Up to 8 characters - lower case Up to 8 characters - case sensitive
Name: _______________________________________________________________________
Address: _____________________________________________________________________
___________________________________________________________________
Home Phone #: _________________ Work Phone #: _________________ Ext: _________

BILLING & PAYMENT PREFERENCES Subscribing: [ ]Monthly $18.95 [ ]Quarterly $55 [ ]per company contract _________________
Billing Options: (All bills due on the first of the month for the following service period.)
[ ]Bill via E-mail account [ ]Bill via postal service (add $1.00 per billing cycle chosen)
[ ]Bill via credit card - (We accept MasterCard and Visa)
Name on Account: ________________________________________
Card #: ________________________________________ Expiration Date: _______________
Signature of cardholder: __________________________________________________________
Please enclose first payment and $10.00 Activation fee with application.

CUSTOMER EQUIPMENT INFORMATION What type of PC do you have? IBM/compatible with [ ]NT [ ]Win95 [ ]Win3.1
Mac/compatible with OS [ ]8 [ ]7.6 [ ]7.5 [ ]7.1
Please describe your modem:
Brand: ______________________________ Model: ______________________________
Type: [ ]Internal [ ]External Speed: [ ]67K [ ]56K [ ]33.6 [ ]28.8 [ ]14.4
Do you have previously installed INTERNET software? [ ]Yes [ ]No
Do you have a dedicated phone line for your computer? [ ]Yes [ ]No
Do you have call waiting? [ ]Yes [ ]No Do you have a cordless phone? [ ]Yes [ ]No

Subscription Agreement
I HAVE READ, AND AGREE TO THE SUBSCRIPTION CONDITIONS AVAILABLE AT
www.echoweb.net/agreement.htm AND I WISH TO OPEN AN ACCOUNT WITH ECHOWEB, LLC.
IF I AM UNDER 18, MY LEGAL GUARDIAN HAS SIGNED BELOW.

SIGNATURE: ________________________________________ Date: ____________________