SULLY TELEPHONE COMPANY DIAL-UP REGISTRATION FORM

NAME: _______________________________________________________

ORGANIZATION:______________________________________________

ADDRESS:____________________________________________________

CITY:___________________STATE: _____________ ZIP:______________

HOME TELEPHONE: ( )_______________

WORK TELEPHONE: ( )_______________

PREFERRED USERNAME:______________________________________

MOTHER’S MAIDEN NAME:____________________________________

DATE OF BIRTH ______/______/_______

Local Calling Area Access 19.95 per month

FREE ADDITIONAL EMAIL ACCOUNTS

You can choose to have up to 4 additional email accounts at no additional charge. You are not required to use any additional usernames. Usernames need to be 15 characters or less.

1^st Additional username:____________________ REAL Name:___________________

2^nd Additional username:____________________ REAL Name:___________________

3^rd Additional username:____________________ REAL Name:___________________

4^th Additional username:____________________ REAL Name:____________________

Additional Email Boxes

5^th Additional username:____________________ REAL Name:____________________

6^th Additional username:____________________ REAL Name:____________________

Please indicate system type WIN 3.1 not supported

Windows 95/98/2000/ME Windows XP WebTV Macintosh