| This
section is required for both dialup and site hosting. |
| Please fill out this form the best
you can. We will call you to go over the details if necessary,
so please be sure to include your daytime phone number. |
required field 
|
| First Name |
|
| Last Name |
|
| Company Name |
|
| Address |
|
| City |
|
| State ,
Zip Code |
,
|
| Daytime Phone |
**Please include A/C |
| Evening Phone |
** |
| Existing email address or Nobody@Limo.Net
|
|
| Reffered to Limo.Net By: |
E-Mail Address or Name |
| Offer Code: |
Printed in ad or CD-Jacket |
| Master Account |
If additional account. |
| |
| Username
and Login Information: |
| This will also be
you E-Mail address: ie: Username@Limo.Net |
| First Choice: |
|
| Second Choice: |
|
| Password: |
|
| Account Type: |
|
| Operating System: |
|
| Dialing In From: |
|
| |
| Billing
Details: |
|
This form will go secure!
If you must see the little lock first you can use this link
and start over.
If not just fill in the form and it will go secure BEFORE
any data is transferred!
|
| Billing Method: |
|
| Name as it appears on Credit
Card: |
|
| Credit Card Type: |
|
| Credit Card Numbers -or- none:
|
|
| Validation
Code on back of Card: |
|
| Credit Card Expiration Date:
|
|
|
|
| Account name as it appears
on your checks: |
|
| Bank Name: |
|
 |
| 9 Digit Bank Transit #: |
Between the smiley faces. |
| Bank Account Number: |
Generally 10 digit(s). |
| Account Type: |
|
| |
| Site
Hosting Details: |
| Domain #1. ie MyDomain.Com |
|
| Domain #2. ie Other_Domain.Net |
|
| Domain #3. ie Money.Org |
|
| Webmaster's Password: |
8 Characters or less. |
| |
| Dialup
and Hosting Services Needed. |
| Services: |
|
Additional
Needs & or Comments:
|
|
|
| |
| Apply
with confidence! Our site is secured by: |
If your Browser supports secure connections please use our
Secure Signup Page: http://newuser.limo.net/isp-form.html
Want to apply via FAX please use our ISP
PDF Form. |
