Print this page!

MAIL-IN SIGNUP FORM
(For Check or Money Order Payments)

I am using this form to:

_____ Make a payment

_____ Setup New Service
We accept signup and your payment via personal check or money order.  You may pay monthly or quarterly, but the due date remains the same as automatic payments.  Payments must be received by our office by the 24th of the month.  If you already have an email address with someone like Yahoo, GMail or Hotmail, please provide it on the e-mail address line.  When your account is setup, we will contact you via Telephone.

If you wish to signup for payment by check or money order, please print this page, fill in all the fields, and mail it along with your check or money order to the address noted at the bottom of the page. We will send a reminder email on the 15th of the month to remind you to send payment. Please make sure we receive your payment by the due date to avoid interruption in service.

If you are using this form to make a payment, Fill in your name, address, Daytime Phone, Username and which package you are paying for.  When we receive the payment you will receive an e-mail to the primary email address on file.

 
Customer Information

Name:       _________________________________

Address:   _________________________________

City:         _________________________________

State, Zip:       _____________________________
Today's Date: _____/_____/_____

E-Mail Address: _______________________________

Daytime Phone #: ____________________________

Evening Phone #: ____________________________
Account Information


Choose a User Name: ________________________  

Choose Another : ____________________________
 (Just in case first choice isn't available.  No Spaces please.)

Choose a Password: _________________________

Please note, that the username you choose will also be your e-mail account username.  Example: If you choose jim22 as your username, that means your dialup login, and email will both be jim22@mtgweb.net

If you request premium service with accelerator, when logging into the accelerator do not add @mtgweb.net. Just use jim22 and your password.

Internet Package Choice    please check one


          _____  Premium Monthly Plan $17.95 Per Month


          _____  Premium Quarterly Plan $50 For 3 Months of Service

 
Method of Payment    please check one  (Money order is best as account is setup upon receiving payment.)


   _____ Check (Payable to: Midwest Internet)

    *Checks are held 7 days before applying funds to account.


   _____ Money Order (Payable to: Midwest Internet)

   *Payment is posted to account immediately when received.
Mail Payment To:

    MIDWEST INTERNET
    P.O. BOX 220582
    ST LOUIS, MO 63122
    ATTN: BILLING DEPT