Trip.net TXCRP131A526 Sign-up Dealer
to
TimcoUSA
date
ALICE DIAL-UP 668-8285, HELP LINE 668-8849 SAN ANTONIO 892-9797, HELP LINE ________
company (optional)
Name
Address
City
State
Zip
Home Phone
Work Phone
Fax
Write Username. 3-8 Characters
Write Password 3-12 Characters
Start with a letter
$19.95
Monthly-$19.95_+ $14.95 set-up
$16.50
$99 (six months prepaid) no set-up fee, no tax
Method
Credit Card
Bill me
Cash-Mail
Check Mail
CrCrd type
MasterCard
VISA-------
AMEX----
Discover
Name as it appears on card
Card Number
Expires:
(Charges will be made during the week preceding the month for which payment is due)
I (We) hereby authorize Timco, Trip.net, hereinafter referred to as "COMPANY, to initiate debit entries (withdrawals) to my (our) credit account as indicated above, and Credit Card company to debit the same to such account. This authority is to remain in full force and effect until COMPANY and Credit Card Company have received written notice from me (or either of us) of this term- ination in such time and in such manner as to afford COMPANY and Credit Card Company a reasonable opportunity to act upon it.
_________________________
Signature
_________________
Date
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DSL AND OTHER SERVICES: EMAIL:
DSLINFO@ALICEUSA.COM
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