surferz.net -

SURFERZ.NET
Customer Registration Form

Customer Name :

Billing Address :

City :

State :

Zip :

Home Phone :

Work Phone :

Service Requested :

Service Requested : $13.95 p/m Unlimited

$25.00 p/m Domain With Unlimited

Service Requested : $13.45 p/m Unlimited (Direct Withdrawl)

Payment Terms : Monthly Qrtly Semi Annual

Payment Type : Credit Card Debit Card Direct Withdrawl Paper Bill

Operating System : Win95 Win98 WinME WinXP Mac Linux
Other :
User Name :	Password :
Email 2 : @surferz.net	Password :
Email 3 : @surferz.net	Password :
Email 4 : @surferz.net	Password :
Number To Dial :
Active Date In Server :	Active Date At House :
Special / Notes :

Refered By :

Taken By :


	Terms of Service