Dial-up Internet Order Form

Complete this form to order Dial-up Internet service. Please leave a phone number and best time to call so that we may complete your order. Once you hit submit this order will be emailed to our customer serivce team.

Name:
Address:
City:
State:
Zip Code:
Phone:			Best Time to Call:
Secondary Phone:
email:
I would like to sign up for:
Basic Dail-Up	$21.95/mo +$15 installation fee
WINAccel	$2.95/mo	This is in addition to your monthly service.
Online Backup	$5.95/mo
Email Only	$5.00/mo	This service allows you to an email, but no access to the Internet.

Preferred User Name:		15 character MAX, three character minimum--no “&” sign or symbols, must begin with a letter
Additional Emails:		You are allowed up to 5 emails, with the @westianet.net domain.

Additional Questions/Comments: