netINS Dialup Registration Form
To apply for your netINS account, print and complete this registration form, sign it, and either FAX or post mail it to the location provided. Email orders can not be accepted. PLEASE PRINT or TYPE.

Type of Account: [  ] Individual [  ] Business

Name:____________________________________________________________

Organization:____________________________________________________

Address:_________________________________________________________

City:_________________________ State:_________ Zip:______________

Home Telephone: (____)____________ Work phone: (____)____________

Preferred Username: ____________________ (15 characters or less)
Social Security # ________-______-_________
Mother's Maiden Name: __________________ (For password security)
Date of Birth: _____/_____/_______

Registration cannot be processed if the above is not filled out completely.
 

PACKAGES: Check all services for which you are applying:

[  ] Local Calling Area Access - $18.95 per month
[  ] Nationwide Access to netINS (800 service) - $0.08 / minute
[  ] Standalone 800 Access - $5.00 per month + $0.08 / minute **Check only if above two are not checked**
[  ] netINS E-mail Only (Requires Internet Connectivity) - $5 / month
[  ] Telnet Access to netINS - $5 / month


Free Additional Email Accounts
You can choose to have up to 4 additional email accounts at no additional charge. You are not required to use any additional usernames. Usernames need to be 15 characters or less.

1st Additional username:__________________ REAL name:________________________
2nd Additional username:__________________ REAL name:________________________
3rd Additional username:__________________ REAL name:________________________
4th Additional username:__________________ REAL name:________________________

Additional Email Boxes
$5 / month per mailbox. Usernames need to be 15 characters or less.

5th Additional username:__________________ REAL name:________________________
6th Additional username:__________________ REAL name:________________________

Please indicate system type: WIN 3.1 not supported
[   ] Windows 95/98/2000/ME   [   ] Windows XP   [   ] WebTV   [   ] Macintosh

BILLING INFORMATION
How would you like to pay for service?      Bill Me  [   ]     Credit Card [   ]

If you select Credit Card above: Card Type: [   ] VISA [   ] MasterCard

Card Holder Name:_________________________________________________________
Card Number:____________________________________CVV:____Exp.(Month/Year):______
Card Holder Address:_________________________________________________________
_____________________________________________________________________________
City/St/Zip:_________________________________________________________________
Daytime Phone Number:(____) ____ - ______

CARDHOLDER Signature:________________________________________

A signature is REQUIRED to process your order. Your signature below indicates acceptance of the billing terms and the netINS "Dialup Terms and Conditions" (below).

Signature: ________________________________________ Date: ____/____/____

How did you hear about netINS service? Referral from Existing netINS customer? [   ]

If yes, Customer Name ______________________ Email address______________ @netINS.net

[   ] Television [   ] Radio [   ] Newspaper [   ] Search Engine [   ] Friend [   ] Other

 
 

netINS INTERNAL USE ONLY     Customer No:_____ -_____ - ________

Return to:

netINS Accounts Administration
4201 Corporate Drive
West Des Moines, IA 50266
FAX: (515) 830-0123

Terms And Conditions

1. By signing this registration form and agreement, you (customer) agree to the following terms and conditions of the service described below.

2. These services are provided by netINS, 4201 Corporate Drive, West Des Moines,IA, 50266-5906.

3. Telephone technical support is available upon activation of your account.

4. All charges will be billed on your approved credit card as described on the the DIALUP REGISTRATION FORM. If for any reason a posting to your credit card is not accepted, your service may be discontinued. An additional registration fee, as well as re-establishment of valid credit, will be required to re-establish service.

5. INS make no express or implied warranty of any kind. There is no express or implied warranty of merchantability or fitness for a particular purpose for the services to be provided by netINS. netINS makes no attempt to verify accurate receipt of any message and is not responsible for any loss of data resulting from delays, nondeliveries, incorrect deliveries or service interruptions, including those caused by the negligence, errors, or omissions of netINS, nor for consequential damages regardless of their cause.

6. Customer agrees to comply with the terms governing use of the netINS network, as they may change from time to time. Any changes to the terms governing use of the netINS network will be posted as warranted on the netINS computer system. http://netINS.net/policy/

7. This agreement shall be governed by and construed in accordance with the laws of the state of Iowa applicable to contracts to be performed entirely within the state.

8. Either party may terminate this agreement at any given time by giving written notice. Such notice is effective when given. Customer is obligated to pay for service through the termination date, as detailed on the final invoice.

9. By accessing and using the netINS computer system, user is consenting to system monitoring for law enforcement and other purposes. Unauthorized use of, or access to, this computer system may subject users to criminal prosecution and penalties. User agrees to indemnify netINS against liability for any and all use of user's account.