P.O. Box 480 Blacksburg, Virginia 24063 540-961-4445    FAX 540-961-4444

Registration Form - 3 Easy Steps to Internet Access:

Step 1) Enter your Personal Information:
 
Name:
 
Address Line 1:
 
Address Line 2:
 
City: 
 
State:
 
Zip Code: 
 
Day Phone #:
(______) ______ - __________
Evening Phone #:
(______) ______ - __________
I will use this 
account for:
 __ Individual
 __ Corporate
 __ Partnership
Other:___________________________

Step 2) Enter Your User Information:
 
Computer Operating System
Modem Information
How did you hear about Blacksburg.Net?__________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
__ Windows 95 __ WebTV
__ Brand:
 
__ DOS __ Unix
__ Model:
 
__  Macintosh  __ Other: _____________
__ Speed:

 
Choosing your Username and Password
Choosing a USERNAME: a USERNAME (Sometimes called a PID or Login Name) is your email name and login name. It can be from 1 to 8 characters long and can contain lowercase & uppercase letters and numbers. Your email address will be USERNAME@Blacksburg.Net . For example the USERNAME JoeUser would have the email address JoeUser@Blacksburg.Net Choosing a PASSWORD: Your PASSWORD may be 6 to 16 characters and at least one character should be a number or symbol. Case is significant in a password. Your password should not be easily guessable. You should not use choices like your date of birth, your spouses name, your dog’s name, or variations of the above.
Username Choice 1:                 Enter Desired Password Below:
Username Choice 2:                                                

Step 3) Choose The Service Plan You Wish To Use:
 
Plan
Access Level
Type of Account
Payment Method
Monthly Rate
Set Up

Annual Cost

Plan 1 Unlimited Access* Dial Up Advance Payment Plan** 
$16.95
$20.00
$203.40
Plan 2 Unlimited Access* Dial Up Credit Card – Billed Monthly
$17.95
$20.00
$215.40
Plan 3 Unlimited Access* Dial Up Cash or Check -- Quarterly prepaid           $17.95          $20.00       $239.40
Plan 4 Unlimited Access* Dial Up Cash or Check – Monthly prepaid
$19.95
$20.00
$239.40
Initial Choice
Choose Your Plan
_____
Plan 1: I wish to SAVE MONEY via the Advance Payment Plan**
_____
Plan 2: I wish to save money by paying monthly by credit card
  Credit Card #:  
Expiration Date:
_____/_____
_____
Plan 3: I don’t care about saving money, just bill me monthly
Setup Fee:
$20.00
* Blacksburg.Net provides Unlimited Interactive Access. See Terms and Conditions for details.

** By paying in one year in advance you get access for ONLY 16.95 PER MONTH

(Form Revision #: 010623)

Prorated Monthly Fee:
$_____.___
Monthly Fee:
$_____.___
Total:
$_____.___

I agree to the above payment arrangement and the attached Terms and Conditions and Acceptable Use Policies of Blacksburg.net

Signature: _____________________________________________ Date: ________________________

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