Today's Date:

-- mm/dd/yy

Please Provide The Following Order Information:

Name
Title
Company
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone
FAX
E-mail

	BILLING ADDRESS (if different)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

Choose The Type Of Service You Prefer:

Standard Dial Up @ $14.50
Dial Up Plus @ $16.50
Speedway High Speed  @  $18.00
Selection Amount	Select $14.50 $16.50 $18.00
Invoice Billing Set Up	$15.00
Total Amount Due	Select $29.50 $31.50 $33.00

 Please Select Your Preferred User Name and Password

User Name
Password
NOTE: Your user name will also be the mail address i. e., <username>@mt-isp.net. We will try to match your user name as requested. Your password must be at least 8 characters that can be integers and text mixed and is case sensitive.

 

Please mail the total amount due selected above payable to:
.
	Millennium Technologies (Miltec) P. O. Box 2542 Yucca Valley, CA 92286
.
Your new Internet access account will be activated and functional within 24 hours after we have received your check.

Any Additional Comments or Instructions: