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Contact Information
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Account Name: |
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__________________________________________ |
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Address: |
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__________________________________________ |
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__________________________________________ |
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Home
Phone: |
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__________________________________________ |
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Work Phone: |
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__________________________________________ |
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Data Phone: |
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__________________________________________ |
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Requested User Name/Email Address: |
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_________________________ |
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_________________________________________________________ |
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Requested Password: |
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______________________________________ |
Payment Options
[ ] Monthly
$19.95/mo + $25 Setup
Credit Card Only
[ ] Quarterly
$59.85/3mo + $25 Setup
Invoice Only
[ ] Annual
$191.40 (no setup fee)
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Name on Credit Card: |
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_____________________________________ |
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Credit Card Number: |
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_____________________________________ |
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Expiration Date: |
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___[ ]
Invoice Me ($25 fee on returned checks) |
Computer System
Operating System: Win 98/Me Win2000
WinNT WinXP Macintosh
Modem Speed: 28.8 KBPS 33.6 KBPS
56 KBPS 128 KBPS (ISDN}
Computer Brand Name: _____________________________________
By signing and dating below, you
agree to pay for all services provided within the terms of this
service agreement. This agreement is open-ended and will be invoiced
or your credit card will be debited automatically. Setup and
activation charges are billed upon activation of service and are
non-refundable. Direct billing to qualified accounts must
be in advance for setup and monthly service base amounts. Direct
billing is due on receipt. Returned checks are subject to a
$25.00 service charge. Cancellation of service under this
contract must be made in writing 30 days in advance of expected
cancellation date. There is NO PRORATING of outstanding charges.
Your signature below indicates that you have sufficient authority to
contract for services on behalf of yourself, your company, or
organization, that you are at least 18 years of age and that
you have read, understand and agree to all of the Terms and
Conditions as outlined on this form. BrandywineNet reserves the
right to cancel this account at any time for any reason.
I
Agree___________________________________________________
Printed Name_______________________________Date___________
BrandywineNet - P.O. Box 520 - Oxford, Pa. 19363
FAX: 610.932.2246
- PHONE: 610.932.6590
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