Atlas Internet Service Order Form

Atlas Internet Service's Order Form

Order Form
(Note: When printed, this form may exceed the length of one page.)
Print out this Order Form, and send it along with Your Check or Credit Card Info to:
Atlas Internet Service, P.O. Box 2868, Chino, CA 91708-2868
or FAX to: 909-902-0134 Customer Information:

Name: ________________________________________________________

Address: ______________________________________________________

City: ______________________ State: ____________ Zip: _______________

Phone Number:_________________________(You must include your phone number!)

Email Address:___________________________________________
Please Note: We do not trade, sell or give any of your information to anybody! We also value our privacy.

User or Domain Name Desired:_________________________________________

Password Desired:_____________________________________________

Desired Access Number:________________________________________

Service's Ordered

Service Requested	____________Description____________	___Price___	___Total___
_________	__________________________________	__________	___________
_________	__________________________________	__________	___________
_________	__________________________________	__________	___________

All Dialup Accounts Have a $20.00 Setup Fee. The Setup Fee has been Waived for
the Standard $14.95 Account. This is a LIMITED Time Offer and it will Expire Soon.
All Web Hosting Accounts Have A $20.00 Setup Fee.

Subtotal of Order	$________________________
Setup Fee	$________________________
TOTAL	$________________________

With Order: I've enclosed $___________________ as Payment.
(Make checks payable to JLH)

Or By Credit Card: Charge my order to my credit card indicated below:
Credit Card Information: Visa or MasterCard.

Card Number _________________________________________ Expires __________

Phone Number (_____)____________________

Name on Card _________________________ Signature _________________________

Atlas Internet Service
P.O. Box 2868
Chino, CA 91708-2868
Office: 909-902-0134
FAX: 909-902-0134