Please fill out this application and mail to the address below. Our fees for DSL are $30/month, two months payable in advance ($60) . Billing will be by e-mail only to your Michiana Free-Net e-mail mailbox. The one-time setup fee is $5.00. To establish your account, your application must be accompanied by a minimum payment of $65.00 which covers your first two months and the setup fee. You will need a DSL modem. We can supply a D-link 2320B which can be configured to PPPoE authentication. This includes modem, power supply, 4 microfilters, one phone splitter, and an Ethernet and phone cable for $45.00. You also have the option to buy a DSL modem on you own. For a completed order, it will take a minimum of 15 business days.

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______
	Present Home Phone Servic - Check one. AT&T ________ Verizon______ Other________
	Last 4 digits of your Social Security number. _________________________________	I have iMac Mac 8.5+ Windows 95 Windows 98 Windows ME Windows 2000 Windows XP

METHOD OF PAYMENT

Monthly

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:___________________________