Service Subscription Form '

Subscriber Information:

 

Contact Name:
Please enter the name of the person who will administer for the account.

 

             What's your name? 
If this is corporate/business, 
     what's the business name? 
                       Address 
                          City 
                         State 
                           Zip 
                  Phone Number 
                    Fax Number 

 

 

Account Information:

Remember to check any of these boxes which are appropriate to your situation:

Please credit my account for one month, I am switching from another provider (current e-mail: )
Six month signup, 10% discount (we will bill you for 6 months)
One year signup, 15% discount (we will bill you for 1 year)

Do you need the Netscape Navigator software?
Please choose one of the following from the list

yes, please include the Netscape software and your online booklet ($35 set up)
no, I already have software ($20 set up)

Desired Login/Password:

Please enter your desired login ID and password on the system.

The account name. This will be your e-mail address and your login name,
i.e., tomjones. Must be 16 characters in length or less 
(if you send in a longer one, it will be chopped)
                  Login name:
And, the account password. 
                               
Again:
                               

 

 

Payment Information:

Visa
Master Card
American Express
Discover
Check(Billed Quarterly)

If paying by credit card, please enter the following information.

Credit Card #:
Expiration Date:  (ie 07/97)
Months of Payment:

Additional Information:

How did you find out about SCescape?

Referred to us by a Current User
Surfing The Web
Search Engine
Reading through newsgroups
Other

My contact e-mail is:


Please read through the service agreement carefully, then click on the button below to subscribe to netaddict's Service.

any questions? Please feel free to call us at 1-888.scescape or e-mail us!