Date:_________ Culcom,LLC 514 West Jefferson Street Culver, Indiana 46511 800-344-6914 574-842-3675 Fax 574-842-3673 EMAIL techsupport@culcom.net Internet Order Form Billing Information: Company Name: _________________________________________________________ First Name: ________________________ Last Name: __________________________ Address: ______________________ City: _____________ State: ___ Zip:___________ Phone Number: Home____________ Work____________ Date of Birth:_______________ Driver's License Number: __________________________________________________ Operating System: Windows Vista_____Windows 2000/XP_____Mac_____Linux_____ Monthly Account: 450 Hours per month. $20.00_____ Yearly Account: 450 Hours per month. $200.00_____ Wireless Home Use 1 computer per month. $50.00_____ Account Activation User Name & Email Address: (lower case) ___________________ @culcom.net Password: _____________ Additional Email Address: (lower case) ____________________@culcom.net Password: _____________ What Number Will You Call To Access The Internet: _____ Plymouth 914-4011 _____ Monterey 212-4028 _____ Lapaz 203-4030 _____ Winamac 946-1000 _____ Bremen 248-4011 _____ Walkerton 586-5000 _____ Millwood 907-4080 _____ North Judson 241-4028 _____ Argos 281-4000 _____ Kewanna 653-4000 _____ Culver 842-8500 _____ Knox 207-4003 Domain Name and Home Page: culcom.net Pop3 and SMTP server name: culcom.net DNS Number: 72.42.204.10 How Do You Want To Pay For Your Account Visa:_____ Master Card:_____ American Express:_____ Direct Bill:_____ Name on Card: __________________________________ Card Number: ___________________________________ Expiration Date: _______________________________ Signature: _____________________________________ Referred by:____________________________