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Print this page! |
MAIL-IN SIGNUP
FORM
(For Check or Money Order
Payments) |
I am using this form to:
_____ Make a payment
_____ Setup New Service |
We accept signup and your payment via personal check or money
order. You may pay monthly or quarterly, but the due
date remains the same as automatic payments. Payments
must be received by our office by the 24th of the month.
If you already have an email address with someone like Yahoo,
GMail or Hotmail, please provide it on the e-mail address
line. When your account is setup, we will contact you
via Telephone.
If you wish to signup for payment by check or money order,
please print this page, fill in all the fields, and mail it
along with your check or money order to the address noted at
the bottom of the page. We will send a reminder email on the
15th of the month to remind you to send payment. Please make
sure we receive your payment by the due date to avoid
interruption in service.
If
you are using this form to make a payment, Fill in your name,
address, Daytime Phone, Username and which package you are
paying for. When we receive the payment you will receive
an e-mail to the primary email address on file. |
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Name:
_________________________________
Address: _________________________________
City:
_________________________________
State, Zip:
_____________________________
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Today's
Date: _____/_____/_____
E-Mail
Address:
_______________________________
Daytime Phone #: ____________________________
Evening Phone #: ____________________________
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Choose a User Name: ________________________
Choose Another : ____________________________
(Just in
case first choice isn't available. No Spaces please.)
Choose a Password:
_________________________
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Please note,
that the username you choose will also be your e-mail account
username. Example: If you choose jim22 as
your username, that means your dialup login, and email will both be
jim22@mtgweb.net
If you
request premium service with accelerator, when logging into the
accelerator do not add @mtgweb.net. Just use jim22 and your
password. |
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Internet
Package Choice
please check one |
|
_____
Standard Plan $36.95 For First 3 Months
($10 per month + $6.95 Setup Fee)
_____
Premium Plan $49.80 For First 3 Months
($13.95 per month + $7.95 setup fee)
**If you are sending in
a payment for an existing account, subtract the setup fee.
This means for Standard
send $30.00 and for Premium send $41.85.
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| Method
of Payment
please
check one |
_____
Check
(Payable to:
Midwest Telecom)
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_____
Money
Order
(Payable to:
Midwest Telecom)
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MIDWEST TELECOM
P.O. BOX 220582
ST LOUIS, MO 63122
ATTN: BILLING DEPT |
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