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    KOSInet On-Line Sign-Up Form


Customer Name (Last, First, Middle Initial)

Street/Billing Address

City  state zip

Current Valid Email

Daytime phone Evening phone

Operating System: 

Please list your first and second choices for your user ID 's and passwords. Please note that your choices will be entered in lower case letters, unless specified by circling letter (s) you wish to capitalize. Your username will also become your email address. Please indicate secondary emails with a #2 notation. NOTE: Username & password are CASE SENSITIVE (lowercase is preferred). No spaces or special characters will be accepted. Indicate "zero" by a slash mark through it -?. PLEASE WRITE LEGIBLY TO PREVENT DELAYS IN PROCESSING.



 Payment Options: Monthly(if you select Credit/Debit Card, Please complete appropriate section below)

Payment Method: VISA MasterCard Discover Check Cash (Please Check only one) 

If you selected the Credit Card options, please complete the information below.

Card #- - - V-Code (Located on the back of your credit card on or around the signature line)

Expiration Date on card ____/______ Name as it appears on card_________________________________________

Customer Agreement for Payment Terms: If paying by cash or check, invoicing will be monthly. If paying by credit card, card will be debited monthly. I have been informed about payment policies and user name preferences. I understand that my choices will be entered in lower case characters, unless I have specified otherwise. I authorize KOSINET to make any necessary changed, due to system requirements, and to inform me of such changes.  ACCOUNT WILL BE VALID WITHIN 24 HOURS OF KOSINET RECEIPT OF THIS FORM.