Printed Name ______________________________________________

Address  __________________________________________________

City, State, Zip _____________________________________________

Telephone  _____________________________

I request my "User Name" be: ____________________________ (no more than 8 characters in length).

I request my password be: _____________________
 

___________                  _________________________________________________
Date                                 Signature

Enclosed is payment in the amount of $_____________ for the first month's service as shown on the Schedule. Make all checks payable to "VFR Digital"

I want my service fees (including any roaming charges I may incur) charged to my credit card. I hereby authorize VFR Digital to charge my service fees to my credit card each month. I understand that this charge will be posted automatically without any further authorization from me and will continue to be so charged until I notify VFR Internet, in writing, to the contrary. I also understand that I will not receive any invoice to confirm each such monthly charge unless I specifically so request, in writing.

Card No. __________________________________________                        Type: _____________
                                                                                                                            (MC, Visa, Am Ex, Discover)
Expiration Date: ______________

Name as it appears on Card: ______________________________________________
 

Computer info:     _____ Windows 3.1     _____ Windows 95     _____ Windows 98
                           _____ Apple                 _____ iMac

Referred by: ______________________________________________
 

Mail to: VFR Internet, PO Box 1246, San Martin, CA 95046 Phone: 800-899-4125 Fax: 408-681-1528