Email Account 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.

Do not fill out this form if you have not yet contacted your Independent Telephone Company first. The phone company in your area could have a different registration for you to use.

This registration is for the netINS Email Account Only! If you need to connect to the Internet with netINS service please use the registration form at http://netINS.net/dialup/dialup-registration.html . This account does not provide Basic Showcase personal web space, that is a free product available with a netINS Dialup Account.
PLEASE PRINT or TYPE. 
	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:____/____/____

Check all services for which you are applying:

  	 [  ] netINS Email Account - $5.00 / month
			(Dialup Connectivity and Basic Showcase web space are NOT included in this account)
CREDIT CARD INFORMATION

  Card Type: [  ] VISA [  ] MasterCard
       
  Card Holder Name:_______________________________________________________________
  Card Number:____________________________________________Exp. (Month/Year):______
  Card Holder Address:____________________________________________________________
                      ____________________________________________________________
          City/St/Zip:____________________________________________________________
  Daytime Phone Number:(____) ____ - ______

  CARDHOLDER Signature:________________________________________
NOTE: Your monthly usage charges will be charged to your credit card unless alternate billing arrangements have been established. To request alternate billing arrangements contact: Account Administration at (515)830-0344. Your signature below indicates acceptance of the billing terms and the netINS “Dialup Terms and Conditions”(below).

A signature is REQUIRED to process your order.
Signature: _________________________________ Date: ____/____/____

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

netINS, Inc.
4th Floor, Merchants Building
312 8th Street
Des Moines, IA 50309
FAX: (515) 830-0345


		netINS  --  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. 

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.

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All text and original graphics copyright © 1997, 2001 netINS, Inc. All Rights Reserved.