| NAME:
_________________________
COMPANY: ________________________________ ADDRESS: ________________________________ CITY, STATE, ZIP ________________, ___ ______ DAYTIME PHONE: (_____) __________________ FAX: (_____) __________________ |
Your
signature on this form and our receipt of your initial payment
authorizes this company to perform services outlined below. Email: ___________________ Real/Time Account: ___________ Signature: ______________________________ Date: ____/____/____ |
| Description of work authorized | OFFICE USE | ONLY |
|
| ¨ Add/Cancel 56k Dialup Access - Username:______________ | $ | ||
| ¨ Add/Cancel ISDN Dialup 64k / 128k Access - Username:______________ | $ | ||
| ¨ Add/Cancel Ded 64k / 128k ISDN Access - Username:_______________ | $ | ||
| ¨ Add/Cancel Ded T1 Access - Username:______________________ | $ | ||
| ¨ Add/Cancel Web Site Hosting - Domain name:_______________________ | $ | ||
| ¨ Register/Modify Domain name:____________________________ | $ | ||
| ¨ Create/Modify Web Design (provide details in the notes section below) | $ | ||
| ¨ Add/Modify Ecommerce Site | $ | ||
| ¨ Install/Teardown Co-located Server | $ | ||
| ¨ Add/Delete/Modify Email Box ___________ forward to _____________ | $ | ||
| ¨ Add/Cancel Email List Server - List Name:_________________ | $ | ||
| ¨ Other: | $ | ||
| Tax Due (8.25%)(Texas only) | $ | ||
| Total Due including Tax | $ | ||
| Balance Due Upon Completion of Project | $ |
Make all checks payable to Real/Time Communications
Setup Fees and payment for first month's service are due upon signing of contract for services. Full payment is due upon installation/project completion. Registration of domain names will be executed upon receipt of final payment for site/homepage design. Service is provided according the the terms and conditions stated within our Terms of Usage and Acceptable Usage Policy, which can be access from our home page at http://www.realtime.com
Please print this out and fax back
to 512-459-3858