Secure Order Form!
Customer Information
 *required fields
*Your Name
Company
*Street Address:
*City   *State
*Zip Code
*Phone #
ex: 800 555-1212 		Fax #  
ex: 800 555-1212
 
Current Email Address - Very Important!  This is where we will send your new account information or contact you if there is a problem with signup.  If you do not have a current email address, we will contact you via the phone number listed above.
Current Email Address

Account Information
*Primary Login Name
(also your primary email address)		 *2nd email address: @flashflow.net
ex: username@flashflow.net
*Second Choice: *Second Choice:@flashflow.net
*Password: *Password:
*Security Word
(Mother's Maiden Name)
Which Network Did You Find An Access Number On?     
What was the Toll Free Access Number You Found?   
Service & Billing Information

*Please Select Your Payment Schedule

56K Dialup Account

56K Dialup Account - $131.40 (12 Months) = $10.95/month
56K Dialup Account - $77.70    (6 Months) = $12.95/month
56K Dialup Account - $44.85    (3 Months) = $14.95/month

64K ISDN Dialup Account

64K ISDN Dialup Account - $215.40 (12 Months)    = $17.95/month
64K ISDN Dialup Account - $119.70 (6 Months)      = $19.95/month
64K ISDN Dialup Account - $65.85 (3 Months)        = $21.95/month
64K ISDN Dialup Account - (Minimum 3 Month Agreement)  $24.95/month

*add $25 setup fee for each account set-up
Billing Information - Service is provided on a prepay basis ONLY!  Your credit card account will be billed each month prior to the next month of service.  Accounts that are declined after two attempts are considered closed and will be suspended prior to the next month of service.  Credit card numbers are verified.  Submitting invalid or stolen card numbers carries stiff legal penalties. Credit cards are processed through our corporate offices as ImagePro Communications.
*Credit Card Number
*Name As It Appears On The Credit Card.
*Select
Credit Card  		     
*Expiration Date: MM/YY

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