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<html>
<head>
<meta NAME="GENERATOR" CONTENT="Microsoft FrontPage 3.0">
<title>C:\Program Files\Munica\FormPAL Trial\internetsignup.html</title>
</head>
<body bgcolor="#FFFFFF" background="backgrnd.gif">
<form name="form1" ACTION="http://www.nemr.net/cgi-bin/internetsignup.cgi" METHOD="post">
<table border="1" width="92%" height="45">
<tr>
<td width="33%" height="39" bgcolor="#000080"><div align="center"><center><p><font
size="5" color="#FFFFFF"><strong><em>nemr.net</em></strong></font></td>
<td width="33%" height="39" bgcolor="#000080" align="center"><div align="center"><center><p><font
size="5" color="#FFFFFF"><strong><em>kvmo.net</em></strong></font></td>
<td width="34%" height="39" bgcolor="#000080" align="center"><div align="center"><center><p><font
size="5" color="#FFFFFF"><strong><em>marktwain.net</em></strong></font></td>
</tr>
</table>
<div align="center"><center><p><font size="4" color="#800080"><strong><em><b>See our <a
href="rates.html">rates</a> and <a
href="numbers.html">service area</a> pages for information on our
internet service. </b></em></strong></font></p>
</center></div><div align="center"><center><table cellpadding="1" cellspacing="1">
<tr>
<th colspan="2" bgcolor="#4E4E9C"><font color="#ffffff">Internet Sign-up</font></th>
</tr>
<tr>
<td bgcolor="#D1D1E9">Billing First Name</td>
<td bgcolor="#D1D1E9"><input NAME="A Billing First Name" TYPE="TEXT" SIZE="20"
MAXLENGTH="30" VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">Billing Last Name</td>
<td bgcolor="#D1D1E9"><input NAME="B Billing Last Name" TYPE="TEXT" SIZE="20"
MAXLENGTH="50" VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">Phone Number</td>
<td bgcolor="#D1D1E9"><input NAME="C Phone Number" TYPE="TEXT" SIZE="17" MAXLENGTH="12"
VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">Billing Street Address</td>
<td bgcolor="#D1D1E9"><input NAME="D Billing Street Address" TYPE="TEXT" SIZE="58"
MAXLENGTH="80" VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">City</td>
<td bgcolor="#D1D1E9"><input NAME="E City" TYPE="TEXT" SIZE="20" MAXLENGTH="50" VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">Zip</td>
<td bgcolor="#D1D1E9"><input NAME="F Zip" TYPE="TEXT" SIZE="12" MAXLENGTH="5" VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">Desired Login Name (3-8 characters)</td>
<td bgcolor="#D1D1E9"><input NAME="G Desired Login Name (3-8 characters)" TYPE="TEXT"
SIZE="14" MAXLENGTH="8" VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">2nd choice for Login Name</td>
<td bgcolor="#D1D1E9"><input NAME="H 2nd choice for Login Name" TYPE="TEXT" SIZE="14"
MAXLENGTH="8" VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">Desired Password (3-12 Letters or Numbers)</td>
<td bgcolor="#D1D1E9"><input NAME="I Desired Password (3-12 Letters or Numbers)"
TYPE="TEXT" SIZE="16" MAXLENGTH="12" VALUE></td>
</tr>
<tr>
<td bgcolor="#D1D1E9">Operating System (check which operating system you have)</td>
<td bgcolor="#D1D1E9"><input
NAME="Operating System (check which operating system you have)" TYPE="CHECKBOX" SIZE="20"
MAXLENGTH="50" VALUE="Windows 3.x">Windows 3.x&nbsp; &nbsp;<input
NAME="Operating System (check which operating system you have)" TYPE="CHECKBOX" SIZE="20"
MAXLENGTH="50" VALUE="Macintosh">Macintosh&nbsp; &nbsp;<input
NAME="Operating System (check which operating system you have)" TYPE="CHECKBOX" SIZE="20"
MAXLENGTH="50" VALUE="Windows 95">Windows 95&nbsp; &nbsp;<input
NAME="Operating System (check which operating system you have)" TYPE="CHECKBOX" SIZE="20"
MAXLENGTH="50" VALUE="Windows 98">Windows 98&nbsp; &nbsp;</td>
</tr>
<tr>
<td bgcolor="#D1D1E9"></td>
<td bgcolor="#D1D1E9"><input
NAME="Operating System (check which operating system you have)1" TYPE="CHECKBOX" SIZE="20"
MAXLENGTH="50" VALUE="WebTV">WebTV&nbsp; &nbsp;</td>
</tr>
<tr>
<td bgcolor="#D1D1E9">Does your computer have a CD-ROM Drive?</td>
<td bgcolor="#D1D1E9"><input NAME="P Does your computer have a CD-ROM Drive?1"
TYPE="CHECKBOX" SIZE="20" MAXLENGTH="50" VALUE="Yes">Yes <input
NAME="Q Does your computer have a CD-ROM Drive?" TYPE="CHECKBOX" SIZE="20" MAXLENGTH="50"
VALUE="No">No</td>
</tr>
<tr>
<td bgcolor="#D1D1E9" COLSPAN="2" align="center"><input NAME="Submit" TYPE="SUBMIT"
SIZE="20" MAXLENGTH="50" VALUE="Submit">&nbsp; &nbsp;</td>
</tr>
<tr>
<td bgcolor="#D1D1E9" COLSPAN="2" align="center">Please fill out all of the information</td>
</tr>
</table>
</center></div>
</form>
<em><b><font size="5" color="#800080">
<p ALIGN="center"><strong>Please do not fill this out if you have already called us and
signed up over the telephone</font><font size="4" color="#800080">.</font></strong></b></em></p>
<p ALIGN="center"><em><b><font size="4" color="#800080"><strong>After you submit this
request for Internet Service we will send you an Easy Internet CD with installation
instructions and a registration form. </strong></font></b></em></p>
<p ALIGN="center"><font size="4" color="#800080"><strong><em><b>We offer all new customers
a 2 week money back guarantee. If you are not completely satisfied with our service return
the CD within two weeks of receiving it for full credit of all charges.</b></em></strong></font></p>
<p ALIGN="center"><font size="4" color="#800080"><strong><em><b>Thank You.</b></em></strong></font></p>
</body>
</html>