Customer Information

Date: _____/_____/_____

Name:       _________________________

Address:   _________________________

City:         _________________________

State, Zip:       _____________________

Company Name:     _____________________

Daytime Phone #:   _____________________

Evening Phone #:   _____________________

Account Information

Choose a Login Name:   ________________

Choose a 2nd Login Name:  ______________
(in case first login is not available)

Choose a Password:   _________________

Security Word:           __________________
(Example: Mother's maiden name)

Email Accounts

Choose a Email Name:   ________________

Choose a Email Name:   ________________

Choose a Email Name:   ________________

Choose a Password:   _________________

Choose a Password:   _________________

Choose a Password:   _________________

Internet Package Choice - Choose One

Monthly Plan 1- $19.95 Monthly Plan 2- $17.95

Method of Payment - Choose One

Check
(Make Payable to Northeast Internet)

Money Order
(Make Payable to Northeast Internet)

Mail Payment To:

Fax Payment & Check To:

Northeast Internet
5 Alden Road
Nanticoke, Pa. 18634

570-733-7302

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