Sign Me Up !
Are You Ready?
We hope you take advantage of the incredible opportunities and resources that the Internet can make available to you. We also hope that you allow jaguNET to be your connection and your guide.
Have you read the jaguNET Connection Contract yet? Before we can sign you up, you must read and agree to the contract.
If you are ready and want to start a jaguNET account, then please fill out and sign the below and mail or FAX the complete package to us. If you are in a rush, we can also take the information over the phone; just fill out the form before you give us a ring:
Personal/Company Name: _____________________________________________
Point of Contact: _____________________________________________
(if Company)
Street Address: _____________________________________________
City: _____________________________________________
State/Zip: _____________________________________________
Phone (day/evening): _____________________________________________
FAX: _____________________________________________
Type of Account:
[ ] Web Publisher Express
[ ] Web Publisher Standard
[ ] Web Publisher Bronze
[ ] Web Publisher Silver
[ ] Web Publisher Gold
[ ] Web Publisher Titanium
Domain Name for Web Publisher: ___________________________
[ ] Other describe: __________________________________________
Term Length: [ ] Monthly [ ] Annual [ ] 2 year
Additional Services: _______________________________________________
Payment Method: [ ] Check [ ] VISA [ ] MasterCard [ ] AmEx
Credit Card Number: _____________________________________________
Expiration Date: _____________________________________________
Credit Card: _____________________________________________
Verification Number
(3 digit number on back of MC/Visa; 4 digit on front of AmEx)
Name on Card: _____________________________________________
Authorized Signature: _____________________________________________
Requested Username (must be 8 or less lower-case characters):
First choice: _______________
Second choice: _______________
The undersigned certifies that the above information is correct. Furthermore
the undersigned agrees to strictly and fully abide by all said Terms,
Conditions, Rules and Regulations described herein:
_____________________________________________ ____________
Signature (SEAL) Date
jaguNET Access Services, LLC
1901 Munsey Drive
Forest Hill, MD 21050-2747
Voice: (410) 420-0140
Fax: (410) 803-2258
© 1994-2012, jaguNET Access Services, LLC
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