DSL provided by

Sully Telephone Company

Name __________________________________________________________________

Address ________________________________________________________________

City___________________State_____________________Zip_____________________

Daytime Telephone ______________ Fax Telephone __________________

Billing address if different __________________________________________________

Preferred Username_______________________________________(15 Characters Max)

Mother’s Maiden Name: __________________________(Needed for password security)

Changing from dialup: ____Yes ____No

If yes, username?_____________________

Local DSL Access $ 45.00/month System Type: System(Choose one)

Mac________

Win95______

Win98______

Imac ______

$ 15 Administrative set-up fee.

Prices and Availability subject to change without notice.

Customer Signature____________________________ Date__________________

Please return this completed form to: Sully Telephone Co

PO Box 308

Sully, IA 50251