|  Personal Information | 
  
    | Name | (required) |  | 
  
    | Telephone # | (required) |  | 
  
    | Email |  |  | 
  
    | 
 
  56kbps Dial-Up Access 
 
 | 
  
    | Connection Plan |  |  | 
  
    |  | * $1/hr charge applicable to extra hour(s) used for hourly plan subscribers. | 
  
    | 
 
  Hi-speed ADSL Internet Access 
 
 | 
  
    | Connection Plan |  |  | 
  
    | Modem Rental |  |  | 
  
    | Activation Fee |  |  | 
  
    | 
 
  Domain & Web Hosting 
 
 | 
  
    | Domain Setup | Domain: |  | 
  
    | Web Hosting |  |  | 
  
    | Extra webspace | x $5.00/month - Additional 5MB/month |  | 
  
    | Extra bandwidth | x $30.00/month - Additional 1GB Bandwidth |  | 
  
    | 
 | 
  
    | Subtotal |  | 
  
    | Taxes |  | 
  
    | Total |  | 
  
    | 
 |