SafeToSurf.net Subscriber Mail / Fax Registration Form:
NOTE:
YOU MAY NOT JOIN if you do not wish to be bound by the terms and
conditions set forth in the PREMIUM ACCESS AGREEMENT ONLINE.
*indicates
required fields
1. *Today's
Date/Join Date:_______________________________________
2. Existing
E-mail if any:________________________________________
3. Name:*First,
Middle, *Last:____________________________________
4. Company:_______________________________________________________
5. *Street
Address:________________________________Ste/Apt#_______
6. *City/Town:________________________*State:____*Zip
Code________
7. *Telephone
Number:____________________Fax Number:________________
8. *Username:________________Choice2______________(4-15
chars/numbers)
9. *Password:_______________________(4-15
chars/numbers-cAsE sEnSiTiVe)
10. *Security
Code or Mother's maiden name:_______________________
11. *Pay
by: [ ]Credit** Card or [ ]Check** (**auto-charge
monthly)
12. Credit
Card Type:____Credit Card Number:___________________Exp:_____
13. Cardholder's
Name:____________________________________________
14. Check
Routing #:___________________ Accnt #:____________Check #:____
I authorize
Internet Billing Service to charge my checking or credit card account
every month.
*Signature:________________________________________Date:____________
Please
Make Check Payable to: Internet Billing Service
In the
amount of: $39.90 for the first two months of service.
Or
Mail to:Internet Billing Service, 501 Route 208,
24/7 TOLL FREE TECHNICAL SUPPORT: (800)-791-2564