Internet Service Order / Payment Form
(DOC#07-14-01-i)

Original order date:
(Keep a copy) MM/DD/YY

Your name:   first                     last

Select the services you want below and the payment plan - One month or three month

Payment
Plan

One Time Fee

Monthly
Fee*
$         

E-mail addr.:           your_current_name@other_domain_name

• Unlimited Dial-up Access
(plus one personal e-mail address & up to 3 aliases
and
one /~“yourusername” website)

 N/A

10
(15 for National)

Mail address: ____________________
City: _______________________,
State: _____________________
ZIP code: ________________

Phone No.: (area code) prefix - ####
Home: ________________________
Business:________________________
Other: ________________________
Fax: ________________________

• Additional Personal e-Mail Address & Website

N/A 

5

• Home Business DSL
(Check for availability)
-Speeds to 784 Kb/s
-One time installation fee of $300.

(A bridge is an additional $260.)

 N/A

55

Desired user names and aliases:
(Choose a unique name of 12 characters or less. Aliases can have more than 12 characters.)

300

95

300

• Domain Name Hosting
The domain name registration is
included if hosted by us for three
months or longer and it is
currently being hosted by
RamonaInternet.com or else it is
$15 per year.

 N/A

10

 N/A

• e-Commerce site hosting
One time setup fee of $50
(+ $100/m on-line operation costs)

N/A

30

50

*Pay in postal m.o. or cash only

Totals:

Internet Services: 1) I am 18 years old or over (circle) Yes or No; 2) If you understand the basics, checkmark here [     ], or checkmark here [     ] if you included a question or comment on the reverse side of this order form; 3) The customer should keep a copy of the filled out order form and the service provider gets the filled out original order form. Note: The service fees are due on the 1st of the month and no later than 30 days. Include your paid amount each time with another (current) payment form.  Mail the filled out internet service order / payment form and the appropriate amount to Richard (at RamonaInternet.com). Thank you.

[(Rec. Paymt. _____ /Initial ____)]      Customer's signature ______________________, Date: _____________