A

Mail Form To;

World Internet Services

Central Brokers ltd 
P.O. Box 6065                                                                           Phone; 928 769 1154
Kingman, AZ. 86402                                                                Fax;     775 628 8669

Phone; 928 769 1154

Fax;     775 628 8669

Fill out and print this form then mail it with your check or money order.       Keep a copy;
When mailing monthly payments, allow 7 days for delivery so your service will not be interrupted
as the system is automated and will have to be reset for late payments. This form is good for
New Signups and Monthly Payments using cash, checks, money orders.

First  Name;
Last  Name;
Street Address;
Mailing Address;
City;
State;
Zip Code;
Phone Number; 
Fax Number;
Date;
User Id;
Pass Word;  6-12 characters 
Amount Enclosed;
Regular dialup $9.95 per mo or HiSpeed dialup $14.95 per mo
Check or M.O. Number;
Monthly Payment or Signup;

Check the form for accuracy and spelling, every thing is entered into the database as received

Comments

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