LocalNet New Subscriber Application
Please fax or mail this completed form using the information listed at the bottom of this page. Please print clearly
Step 1: Subscriber Information (required fields marked with a "*")
First Name*: ___________________________________ Last Name*: __________________________________ Company: ____________________
Address 1*: ____________________________________________________ Address 2: ___________________________________________________
City*: _______________________________ State / Province*: ____________________ Zip Code*: __________ Country*: _________________
Home Phone*:   (        )________________________ Work Phone:   (        )________________________ Fax:   (        )________________________
Step 2: Service Information (both fields are required)
Select your Service Type (check only one):
___ LocalNet's Unlimited Dialup Internet Access ($9.95/mo.)
___ LocalNet's Unlimited Dialup Internet Access plus Express Accelerated Service ($12.95/mo.)
Select your Billing Interval (check only one):
___ Every month   ___ Every 3 months   ___ Every year
Note: a one-time setup fee of $12 applies to all new accounts.
Step 3: Login Information (both fields are required)
Create a LocalNet Username (please print clearly):
Choice 1: _____________________ Choice 2: _____________________
Your username will be part of your primary email address (i.e. username@localnet.com) and is used when logging into our services. Usernames must be 4 to 20 lowercase letters or numbers, and may not begin with a number.
Create a LocalNet Password (please print clearly):
This password is used when retrieving email and when logging into our services. Your password must be a combination of 6 to 8 numbers, lowercase and uppercase letters. Always keep your password confidential.
Step 4: Payment Information (choose one payment method below)
If paying with a Credit Card:
Card Type (check one):
___ Visa ___ Mastercard ___ Novus / Discover
Card Number: ______________________________________________
Expiration Date: ________/_________
Name on Card: ______________________________________________
If paying with a Checking / Savings Account:
Account Type (check one):
___ Savings ___ Checking

Routing Number: _________________________________________
Account Number: _________________________________________
Step 5: Software Information (required)
Check the line below if you would like a free setup software cd (Windows and Mac OS 8-9 only):
____  Yes, I would like LocalNet to send me a free setup software cd
Check the line nex to your Operating System (check one):
____  Win 95/98/ME ____  Win XP ____  Win 2000 ____  Win NT 4 ____  Mac OS 8-9 ____  Mac OS X ____  MSN TV ____  Other
Step 6: How did you hear about us? (optional, please check all that apply)
__  Referral __  Newspaper __  Newspaper Insert __  Phone Book __  Postcard __  TV/Radio Ad __  Web Search __  Menu Ad __  Online Ad __  Our Web Site __  Other
If you have a Referral Code, please write it here: __________________________________________

By signing this application you affirm that you have read LocalNet's Acceptable Use Policy and Service Agreement. You also agree that LocalNet is not responsible for any long distance telephone charges incurred when connected to our service. If you have any doubt whether dialing one of our access numbers is a local (non-toll) call for you, please ask your local and/or long distance telephone provider.

Signature: __________________________________________________________ Date:: _______________________________
Fax: 1-815-550-9929     Mail: LocalNet Corp. - 325 Hampton Hill Drive - Williamsville, NY 14221