INTERNATIONAL ONLINE

Signup for Internet Access!

Please enter all information and one of our technicians will contact you by phone to complete the signup process.

Customer Information
First Name:	(John)
Last Name:	(Public)
Middle Initial:	(Q)
Company Name:	(Widgets, Inc.)

Billing Address And Information
Address:	(123 Anywhere St.)
Apt. Name:	(1, 2-A, Apt-D, or 1-1/2 )
City:	(Whoville)
State:	(WV)
Zipcode:	(12345)

Phone Number:	(required for contact)

Payment Options
I am interested in your following billing option... Check / Money Order Credit Card / Debt Card
I am interested in your following billing Cycle... Monthly Quarterly Semi-Annual Yearly
Are you a Student? Yes I am No I am not
Are you over the age of 55? Yes I am No I am not

Dial Up Connection Information
Username:	(2-25 characters long)
Password:	(at least six characters long)

Your E-Mail addresses can be at these posibillities: username@iolinc.net Or username@westvirginia.net Please select which one you would like... @iolinc.net @westvirginia.net


Additional Information (optional)
How did you hear about IOL?
Last or current Internet provider:	(Earthlink, AOL, Compuserve)

Note: Not all usernames and email addresses are available; we will try to work as close as possible to find a matching username you would like to have. This form does not completely sign you up online. An IOL sales consultant will contact you by phone to go over all account possibilities and complete the signup process.