Richman Poorman, Internet
607 SE Everett Mall Way STE D
Everett, WA  98203
425-353-6900

Sign-Up Today for RPiNet's 56k v.90 Internet Services

1st - Fill Out & Sign this "Sign-Up for Internet Access Application."
2nd - Sign an "RPiNet Terms & Conditions of Use Form."
3rd - We create your Account, You Pay the Bill, "Your Online Today!"

Customer:

Contact:

Phone 1:

Address:

Phone-2:

City:

State:

Zip:

Operating System:

Modem:

Enter desired Username:@richpoor.net
  e-mail address equals: "username"@richpoor.net(3 to 12 Characters Long  - No Symbols)

Enter desired Password:

Select Desired 56k Internet Account:

Account SetUp Fee:

56k v.92 Unlimited Dial-Up @ $ 17.95 monthly

56k Set-Up @ $ 15.00

56k v.92 Unlimited Dial-Up @ $ 48.00 quarterly

Promo  New System Trial

56k v.92 Unlimited Dial-Up @ $ 180.00 yearly

56k N/C Set-Up @ $ 0.00

Extra Alias e-mail Acct(s) = @ $1 Per Month
Extra POP e-mail Acct(s) = @ $3 Per Month
Formula = (Accts (x) e-mail fees (x) Months in Billing)

List all extra E-Mail Accts Below

Recurring Bill: $: Extra e-mail $:

Recurring Total:

Prorate: Days Left in Month (x) $ 0.598 per Day

Total Prorated:

Method of Payment: CashMoney Order Check
Charge My: Visa M/C Discover AMEX Card

Set-Up Fee:

Card #:Exp:

Total Due:

Set-Up By:

 Paid Thru:

Total Paid:

I, Agree to the above Payment Plan & Services____________________________________
Please sign the Terms & Conditions of Use Agreement on the reverse side...