Please fill out this application and mail to the address below. Our fees for IndividualAccounts are $15/month payable quarterly in advance which includes a dailup Internet connection, a wireless Internet connection if you are in downtown South Bend and e-mail. Billing notification will be by e-mail only to your Michiana Free-Net e-mail mailbox. There is a one-time initial fee of $2.00 to cover setup costs. To establish your account, your application must be accompanied by a minimum payment of $47.00. Access is unlimited. If you are under 18 years of age you will need a parent's signature. Local numbers for Elkhart Co. are also available. WIRELESS INTERNET: If you are in the downtown South Bend area and do not have an account, you can use our transient wireless service for $5/day or $15/month.

ACCOUNT INFORMATION PLEASE PRINT OR TYPE

	I would like to sign up for a basic Internet connection and e-mail.	_____________________________________________ Name
	REQUIRED: I would like my User ID to be: (small letters, not less than 5 & not more than 8 characters) __________________________________________________	_____________________________________________ Address
	REQUIRED: I would like my password to be (small letters at least 5 & not more than 8 characters, use some numbers, $ or % if possible)______________________.	_____________________________________________ CityStateZip
	I would like to sign up for business Web pages. It is an additonal $5/month.	_____________________________________________ Telephone: WorkHome
	I understand the Free-Net depends on underwriters to maintain its services. I would like to contribute $__________________	IMPORTANT!!!
	I would like Wireless Internet______
	I am under 18 and would like an account. Parent's Signature_________________________________	I have iMac Mac 8.5+ Windows 95 Windows 98 Windows ME Windows 2000 Windows XP

METHOD OF PAYMENT

Quarterly

Semi-annually

Annually

Totals:

Check enclosed made payable to
Michiana Free-Net Society, Inc.Basic Connect Fee: __________

Please charge my: VISA Mastercard	Fees for Web pages: __________
_________________________________________ Account No.Expiration Date	Donations:__________________
______________________________________ Signature	Grand Total:__________

**I have read all 4 pages of the User Service Agreement, and agree to abide by the rules set forth in it. Signature is required

Signature__________________________________________________________ Date:___________________________