Attitude Online Dialup

Sign-up Form

 

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This form is used to gather the necessary information required to process your request for service.  All information is confidential and is used only for billing and account creation purposes.

Please Note: If you are already an Attitude Online subscriber, and do not wish to open a second account, please do not submit this form. 

Thank You.

Personal Info:

First Name Middle Initial

Last Name

Company Name

Address Line 1

Address Line 2

City State Zip

Home Phone (Including Area Code)

Work Phone (Including Area Code)

Date of Birth

Account Info:

User Name Must be between 3 and 12 characters long letters and numbers.

User Name (First Choice)

User Name (Second Choice)

User Name (Third Choice)

Password Must be between 6 and 12 characters long. Letters and numbers, not a name.

Password

Re-Enter Password

Account Type:

Billing Info:

Visa Master Card American Express Discover

Card NumberExp. Date

Social Security Number

Computer / Software

Operating System

Computer Type

Modem Speed Baud

If 56k

Send Software (PC Only)

How did you hear about us? If it is another user please include their name and user name so we can give them a free month.