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Home Request for Internet Service

RURAL NETWORK SERVICES
INTERNET REQUEST FORM

This is a request form. A RNS representative will be in contact with you to verify information, collect payment, and activate the service.
Payment for setup and 1 month service is due at time of activation (unless otherwise advertised).

FIRST NAME LAST NAME
USERNAME*
(3-12 characters all lower case)
(AZ 3-16 characters all lower case)
 PASSWORD
(6-8 characters all lower case)
(AZ 6-8 characters lower case containing both letters and numbers)
COMPANY BILL TO PREFERENCE
HOME PHONE WORK PHONE
ADDRESS CITY
STATE ZIP CODE

Note*: Your 1st E-mail address will be: username@ruralnetwork.net OR username@theriver.com (For AZ Customers)

DIAL-UP CITY OPERATING SYSTEM
ADDITIONAL EMAIL BOXES
2nd Email Box Username Password
3rd Email Box Username Password
NOTE: There is a $5.00 Charge for each additional Email Box for Arizona Customers.
PLAN & BILLING CYCLE
 Only plan available for Arizona and Stanley customers is unmeasured.
Annual and Semiannual accounts are available, with an included 10% discount.		 There is a $15.00 setup or $10.00 transfer fee on all new internet only accounts (unless otherwise advertised).
 

DATE

 Ex. 07/01/02 Payment may be remitted each month upon receipt of your statement, or you may call our office to set up automatic monthly payment using a credit or debit card.
COMMENTS:

RNs - Internet Sign-up Form
414-8372 or (800)504-8887
www.ruralnetwork.net
support@ruralnetwork.net