mainetelnet.com Subscriber Mail / Fax Registration Form

NOTE: YOU MAY NOT JOIN if you do not wish to be bound by the terms and
conditions set forth in the PREMIUM ACCESS AGREEMENT ONLINE.

*indicates required fields 1. *Today's Date/Join Date:___________________________________________

2. Existing E-mail if any:______________________________________________

3. Name:*First, Middle, *Last:__________________________________________

4. Company:_______________________________________________________

5. *Street Address:________________________________Ste/Apt#___________

6. *City/Town:________________________*State:____*Zip Code_____________

7. *Telephone Number:____________________Fax Number:_________________

8. *Username:________________Choice2______________(4-15 chars/numbers)

9. *Password:_______________________(4-15 chars/numbers-cAsE sEnSiTiVe)

10. *Security Code or Mother's maiden name:_____________________________

11. *Pay by: [ ]Credit** Card or [ ]Check (**auto-charge monthly)

12. Credit Card Type:____Credit Card Number:___________________Exp:_____

13. Cardholder's Name:______________________________________________

14. Check Routing #:___________________ Accnt #:____________Check #:____

I authorize Internet Billing Service to charge my credit card account every month.

*Signature:________________________________________Date:____________

Please Make Check Payable to: Internet Billing Service in the amount of: $33.90 for the first two months of service.

Or Mail to:Internet Billing Service, 501 Route 208, Monroe NY 10950
Or FAX a voided check attached to this to: 1 (845) 783-5989

24/7 TOLL FREE TECHNICAL SUPPORT: (877) 701-8074