INTERNET SERVICE PROVIDED BY
GOLDFIELD ACCESS NETWORK
(515) 825-3996
Click the "Print" button on your browser to print a copy of the Internet Sign-up Form. Return completed form by mail or fax. |
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INTERNET SERVICE PROVIDED BY GOLDFIELD ACCESS NETWORK (515) 825-3996 |
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| LOCAL DIAL-UP: ___________________ |
(PLEASE TYPE OR PRINT)
ADDRESS:____________________________________________________________________________
CITY: ____________________________________ STATE: __________________
ZIP: _____________
SOCIAL SECURITY NUMBER: _____________________________
HOME PHONE: __________________________________________
PREFERRED USERNAME:
_________________________________ (8 CHARACTERS MAX)
PREFERRED PASSWORD:
_________________________________
____ LOCAL CALLING AREA ACCESS $16.95 SPAM FILTER ______Yes ______No
____ ADDITIONAL E-MAIL $5.00 (EACH) PREFERRED USERNAME: _________________________
PREFERRED PASSWORD: _________________________
OPERATING SYSTEM (CHOOSE ONE):
____ WIN95
____ WIN98
____ WIN-ME
$10.00 ADMINISTRATIVE SET-UP FEE
____ WIN-XP
____ MAC
____ iMAC
____ WebTV
____ Internet TV
PRICES & AVAILABILITY SUBJECT TO CHANGE WITHOUT NOTICE. |
By signing this request for Internet service, the Customer agrees to the priveleges and terms found in Goldfield Access Network's and Goldfield Telephone's acceptable use policy. This policy can be found on our website at http://www.goldfieldaccess.net/gan_aup.htm or by visiting our office. |
CUSTOMER SIGNATURE:
_________________________________________
DATE: __________
AUTHORIZED TELCO SIGNATURE: _________________________________ DATE: __________
| Please return this form to: Form Revised: 08/03/05 |
Goldfield Access Network P.O. Box 67 Goldfield, IA 50542 Phone: (515) 825-3996 |
For Office Use Only: |
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Service call 1-888-825-3996 or 515-825-3996