Sign Me Up !

Are You Ready?

We hope you take advantage of the incredible opportunities and resources that the Internet can make available to you. We also hope that you allow jaguNET to be your connection and your guide.

Have you read the jaguNET Connection Contract yet? Before we can sign you up, you must read and agree to the contract.

If you are ready and want to start a jaguNET account, then please fill out and sign the below and mail or FAX the complete package to us. If you are in a rush, we can also take the information over the phone; just fill out the form before you give us a ring:

 Personal/Company Name:  _____________________________________________

 Point of Contact:       _____________________________________________
  (if Company)

 Street Address:         _____________________________________________

 City:                   _____________________________________________

 State/Zip:              _____________________________________________

 Phone (day/evening):    _____________________________________________

 FAX:                    _____________________________________________

 Type of Account:

      [ ] Web Publisher Express
      [ ] Web Publisher Standard
      [ ] Web Publisher Bronze
      [ ] Web Publisher Silver
      [ ] Web Publisher Gold
      [ ] Web Publisher Titanium
           Domain Name for Web Publisher:  ___________________________

      [ ] Other describe:   __________________________________________
      

 Term Length:         [ ] Monthly     [ ] Annual     [ ] 2 year


 Additional Services:  _______________________________________________


 Payment Method:      [ ] Check    [ ] VISA    [ ] MasterCard    [ ] AmEx

 Credit Card Number:     _____________________________________________

 Expiration Date:        _____________________________________________

 Credit Card:            _____________________________________________
 Verification Number
 (3 digit number on back of MC/Visa; 4 digit on front of AmEx)

 Name on Card:           _____________________________________________

 Authorized Signature:   _____________________________________________


 Requested Username (must be 8 or less lower-case characters):

 First choice:           _______________
 
 Second choice:          _______________

 
The undersigned certifies that the above information is correct. Furthermore
the undersigned agrees to strictly and fully abide by all said Terms,
Conditions, Rules and Regulations described herein:



_____________________________________________    ____________
Signature (SEAL)                                 Date