For tech support please call : 329-2151
________________________________________________________________________________________________________
Accountholder Information
/ Signup Form
Accountholder Information
_______________________________________________________________________
First Name Last
Name M.I.
Billing Address
______________________________________________________________________
__________________
______ __________
(______)_______-___________
City State
Zip Phone
Date of Birth (For account security) ____/_____/_____
Requested Username: ________________ @pracon.net ( Minimum 3 Alphanumeric
Characters)
Alternate Username 1: ________________
@pracon.net ( In case first choice is already taken)
Alternate Username 2: ________________
@pracon.net ( In case second choice is already taken)
Requested Password: __________________ (Minimum 6
Alphanumeric Characters) Example: J2r$0!z
Use punctuation, lower case letters, upper case letters, and
numbers to make your password harder for others to guess!
| Operating System: | Service options: |
| ___Windows 95 | ___
Dial-Up Internet Access - $19.95/mo (up to 3 E-Mail Accounts) |
| ___Windows 98 | |
| ___Windows ME | ___ Additional E-Mail Account (Call for Pricing) |
| ___Windows XP | |
| ___Windows 2000 Professional | |
| ___Windows NT 4.0 | |
|
___MacOS 8.0 or Higher |
|
| ___WebTV |
| Method of Payment: | Pro-Rated Rates: | |
|
___Cash |
Sign up between or on the one of the following days and your pro-rated rate will be as listed: | |
| ___Check | 1 - 6 | $19.95 |
| ___PayPal | 7 - 12 | $14.95 |
| 13 - 18 | $9.95 | |
| 19 - 24 | $4.95 | |
| 25 - 31 | $0 | |
___________________________________
_____________
I have read the Acceptable Use
Policy
Date