Internet Access Request

Send a request for an JONG.COM Internet account.

First Name:
Last Name:
Current Email Address:
Phone:
Fax:
Street Address:
City:
State:
Zip:
User name requested:
Use lower case letters and/or numbers only - no spaces 12 CHARACTER LIMIT
Email name requested:
Use lower case letters and/or numbers only - no spaces 8 CHARACTER LIMIT
Password requested:
Use lower case letters and/or numbers only - no spaces 8 CHARACTER LIMIT


Computer System: PC
Mac


Operating System: Windows 3.11
Mac OS 7.0-7.1 		Windows 95
Mac OS 7.5 		Windows NT


Requested Plan: $15.95 Unlimited


How did you find out about us: The List
Friend or Relative
Current customer
Pac Bell Yellow Pages
Valley Yellow Pages
GTE Yellow Pages
Local Touch Yellow Pages
Newspaper
Computer Currents
Micro Times
California Computer News
Radio
Television
Other:



Payment Type:


Credit Card Information: ( if applicable )
Credit Card Number:
(Call 510 845-4811 for phone entry or fax 510 845-2400)
Expiration Date:
Name On Card:
Credit Card Bank Name:
Billing Address for Credit Card:
(if different than above)



Other Comments:
Sales Rep (if applicable)

 
Please send payment. For unlimited account, send $15.95 for first month plus $15.00 for setup (add $10.00 for each email setup). You may have automated credit card billing by sending an authorization to charge your card for internet services. Mail to:

Winners Circle Systems
2618 Telegraph Avenue
Berkeley, CA 94704

Internet and E-mail setups are one time charges and are good for the life of your account