Internet Connect Company - Dial-Up Sign Up form

| Atlantic.net - Internet Connect Company |

Account Information

Dial-up Location to be used:

Dial-up plan:

Login Name*: (minimum 3 characters, no more than 8, all lowercase, must begin with a letter)

Password: (minimum 5 characters, no more than 8)

The customer's email address will be login name*@atlantic.net and the first email that they will receive will be our Acceptable Use Policy. It explains our policies and procedures. Please tell them to go through it carefully.

Contact Information

Company Name:

Customer Name: (as it appears on the credit card or bill)

Address:

Address line 2:

City | State | ZIP Code:

Home Phone:

Work Phone:

Billing Information

Billing Period: Statement Method: Guarantor username (leave blank if none):

Open account with credit card, then switch to quarterly paper invoices.

Setup Fee:

If the Customer is to be billed for service, omit the credit card information below:

Credit Card Type ACH Account Number

Bank Name ACH Routing Number

Credit Card Number

Expiration Date (MMYY example: 0198)

Operating System:

Send setup disk/CD-ROM by mail (if not selected, no label will be printed)

How did they hear about us?

If referral, enter referrer's username

Other:

Best time to call to assist:

Additional Comments: (only use if you want to generate an email to billing)

Sales Person ID:

The account will be created when you click the SUBMIT button. Go through this final checklist to make sure everything is clear with the customer. Make sure the customer writes down each of the following items. The checklist must be completed in order to submit the account.
Final Checklist:

They know their new login name.

They know their new password.

They know their new email address.

They know the local ICC dialup number.

They know the approximate charges for their service.

They have the information on the payment type they selected:

Credit Cards are billed the 15th of the month.

Direct withdrawal from their checking accounts will occur on the 15th of the month.

If they are invoiced they will receive the bill quarterly.

They have the Member Services number, 1-800-921-9328.

Have you mentioned the referal program, unless they are on the Promo plan?

Billing Period:	Statement Method:	Guarantor username (leave blank if none):

Credit Card Type	ACH Account Number

Bank Name	ACH Routing Number

Credit Card Number

Expiration Date (MMYY example: 0198)

*The customer's email address will be login name@atlantic.net and the first email that they will receive will be our Acceptable Use Policy. It explains our policies and procedures. Please tell them to go through it carefully.

The customer's email address will be login name*@atlantic.net and the first email that they will receive will be our Acceptable Use Policy. It explains our policies and procedures. Please tell them to go through it carefully.