Amicron Internet Account Setup Form

If you are interested in setting up an Internet account for your home or office, please fill out this form and click on the submit button at the bottom. Accounts are usually set up within 24 hours. We will contact you as soon as your account is ready.

User Information:

Please enter the following information concerning the primary user of the account. If paying by credit card, the billing address must be the address on the credit card. If you currently have an Email account, please enter it below if you wish to be contacted via Email.

Name:
Company:
Billing Address:
City, State, ZIP:
Phone:
Fax:
Current Email:

 

Billing Information:

Please enter the following information regarding your credit card for payment (if you wish to prepay by mail, simply print this form and mail or fax it to us with your payment).

Credit Card Type: Visa MasterCard
 		Discover
 		Check / MO
Card Number:
Expiration Date:
Service Plan:

 

Email Username & Password

Please enter a username and password for your email account. Your username should be at least 5 characters long, beginning with a letter, and should be no longer than 20 characters. Please note that most common first names (Bill, Sue, Joe, etc.) are not available. Please enter in your 1st and 2nd choices, in case your 1st choice is not available.

Username (1st choice): @
Username (2nd choice): @
Password:

 

Other Questions

Who is your current Internet provider:
Where did you hear about Amicron?
Do you have a need for multiple users to be able to share an Internet connection in your home or office?
Would you like more information on Internet training that our company offers?

 

Notes or Special Promotions

Please enter any notes you wish below. Also, if you are responding to any special advertisements or other promotions, please indicate so here.

 

By clicking on the Submit Application button below, you are acknowledging that you are placing an order for Internet service and that your credit card will be billed based upon the pricing indicated on our Dialup Service page. 

You also acknowledge that you have read and agree to the terms and conditions in our Amicron Internet Terms & Usage Policy. If you have any questions, please contact us. 

 

 

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