DIALUP AND  HOSTING  ORDERING

Please provide the following contact information:

First name
Last name
Title
Organization
Street address
Address cont.
City
State/Prov
Zip/Postal
Country
Work Phone
Home Phone
FAX
E-mail

Desired Username and Password.

Username:  Password:

Do you need web hosting space at this time?

Yes No

If so, What type of hosting space do you need?

Microsoft ® FrontPage ® 2000 Conventional with Unlimited FTP

Choose one of the following options:

Low Use Package $ 9.95 Unlimited Attended  $ 14.95 Personal Web $ 19.95 Business Web $ 29.95 Commercial Web $ 49.95 Corporate Web $ 69.95

What will you use the web site for?

How many Mail Boxes will you need?

What names do you want for the mailboxes?

Do you need a domain name?:  (Want to have yourownname.com etc.)

Yes No

Do you have a domain name that needs to be  transferred to USIPP.NET.

Yes No

If you need a domain name registered, please list  several options.The name will be something  like yourname.com. If you are transferring please  enter it below.

When is the best time for our service representitive to contact you? Also, use this  field to enter your Microsoft® FrontPage®  2000  Registeration Number for Special Offers.

Which Operating System do you use?

Windows 95 / NT 4.0 Windows 3.x / NT 3.5 Mac OS2 Unix / Linux Other

I dial  locally to one of the following cities:

Springfield, Missouri

My modem speed is:

14.4K 28.8K 33.6K 56.6K Don't Know

By submitting this form I have agreed to the terms and conditions of this service.

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