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Dialup Signup

Customer Address
Name:  
Company (optional):  
Address:  
Address (cont.):  
City, State, Zip:    
Telephone:   () -
Fax:   () -
E-mail:  
Bill to this address?   Yes   No
DCANet Customer ID:
(existing customers only)  
Billing Address (If different than above)
Name:  
Company (optional):  
Address:  
Address (cont.):  
City, State, Zip:    
Telephone:   () -
Fax:   () -
Account Information
Account Types:
  • Basic PPP: 20 hours per month.
    (Includes: 1 x E-mail account.) - $9.95/month
  • Extended PPP: 360 hours per month.
    (Includes: 1 x E-mail account.) - $14.95/month
Account Type:  
Username:  
Password:  
Retype Password:  
Please enter any additional comments below:
  

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