Why Pay More

Fill out the form in its entirety to be on your way to your
Internet Connection to the World Wide Web.

BRICK/DONZE INTERNET ACCESS

Date

1) PERSONAL DATA

NAME:
ADDRESS:
ADDRESS:
CITY:
STATE:
ZIP:
DAYTIME PHONE
EVENING PHONE

2) PRESENT E-MAIL ADDRESS

E-Mail Address

3) INTERNET ACCESS ACCOUNTS

Analog (28.8Kb-56Kb)PPP (Home or Business Phone)

$50 Quarterly (3 months) $150 Annually

4) BILLING DATA:

Mastercard Visa Discover American Express

Card Number
Expiration Date	(mmddyy / mmyy)

Bill Invoicing: E-Mail Hardcopy by US Mail ($2 per invoice)

If your Credit Card Information is different from Personal Data,
Please enter Card Holder's Info Here.
Card Info is Same as Personal Data: Yes No

Name As It Appears on Card:
Card Holders Billing Address:
Card Holders Billing City:
Card Holders Billing State:
Card Holders Billing Zip Code:
Card Holders Daytime Phone:
Card Holders Evening Phone:

5) USER ACCOUNT ID AND PASSWORD

USER NAME

1ST CHOICE

2ND CHOICE

3RD CHOICE

PASSWORD

Your username is who you are. It is your identity on our system. It is used in your email address. We request that you give us three choices for your username.
We will alert you which one is used. User names must be made up of only numbers and lowercase letters. No special characters allowed. Your ID must be between 5 and 8 characters.

Password Rules:

Must be between 3 and 8 characters
May not be the same as your username or phone number
May not be your real name
May contain upper and lower case letters
May contain numbers and certain symbols

6) How did you hear about Brick/Donze?

suntimesnews.com KSGM/KBDZ Radio Other (specify)

7) If you have special requirements or comments, place them here:

Before Pressing Submit, Please review to insure no corrections are needed
If you would rather fill out the form, print it out, and fax it to us, our fax number is 573-883-2866.