Internet Registration Form

Name: ________________________________________________________________________

Business Name (if for business):_______________________________

Address:_______________________________________________________________________

City:___________________

State:______

Zip:______________

Work Telephone:____________________

Home Telephone:_____________________

Employer:_____________________________________

Town:_______________________

SS#______________________

Mother’s maiden name (for password security):___________________

Preferred User Name:__ __ __ __ __ __ __ __ __ __ __ __ __ __ @ win-4-u.net ~(Will be used for email) (15 character MAX),(3 character minimum--no “&” sign or symbols, must begin with a letter)

Preferred Password_______________________

Billing Information, if different from above:

Name:______________________________
Address:____________________________
City:____________ State:____ Zip:______

Packages:
( ) Local Access $21.95/month (Unlimited Usage)
( ) Local Access $19.95/month with WIN Premier Long Distance* (Unlimited Usage)
( ) Local Access $19.95/month with WIN One Rate Long Distance** (Unlimited Usage)
( ) Additional E-mail accounts $3.00/month (one e-mail is included with Local Access)

Additional E-mail usernames:_______________________ __________________________

*15/14 cents per minute billed in 6 second increments
**10 cents per minute billed in 6 second increments $4.95/month service charge

PLEASE SPECIFY OPERATING SYSTEM:

(Choose One) Mac___ iMac___ Win95___ Win98___ Win2000___WebTV___ Internet TV___ WinXP___
Signature___________________________________ Date________________________

$15.00 Adminstrative Set-up fee and first full month of service required at time of activation.
Prices and availablity for residential and business Internet service subject to change without notice. Please call for current pricing.

Internet Registration Form

$15.00 Adminstrative Set-up fee and first full month of service required at time of activation.
Prices and availablity for residential and business Internet service subject to change without notice. Please call for current pricing.

Please return completed form to:

Western Iowa Networks
112 E Main St., P.O. Box 280
Breda, IA 51436
office: 888-508-2946
fax: 712-673-2800

For Office use only:
BTC, Inc. Authorized Telco Signature_______ Date

Internet Registration Form

$15.00 Adminstrative Set-up fee and first full month of service required at time of activation. Prices and availablity for residential and business Internet service subject to change without notice. Please call for current pricing.

Please return completed form to:

Western Iowa Networks 112 E Main St., P.O. Box 280 Breda, IA 51436 office: 888-508-2946 fax: 712-673-2800

For Office use only: BTC, Inc. Authorized Telco Signature___________________________ Date____________________

$15.00 Adminstrative Set-up fee and first full month of service required at time of activation.
Prices and availablity for residential and business Internet service subject to change without notice. Please call for current pricing.

Western Iowa Networks
112 E Main St., P.O. Box 280
Breda, IA 51436
office: 888-508-2946
fax: 712-673-2800

For Office use only:
BTC, Inc. Authorized Telco Signature_______ Date