Contact/Billing Information

Username:______________________________________________ Password:__________________________

Customer Name: ______________________Business Name:__________________________________________

Billing Address:_____________________________ City:________________ State:____ Zip:________________

Phone:_________________ Fax:__________________ Install at______________________________________

Service Offered
__ 512k service with a CIR* of 100k- - 5 Email Accounts - $80.00 setup fee - $40.00 per month
*CIR = Committed Information Rate
Email Addresses:

1.         Username:_________________________@power-net.net Password _______________________

2.         Username:_________________________@power-net.net Password _______________________

3.         Username:_________________________@power-net.net Password _______________________

4.         Username:_________________________@power-net.net Password _______________________

5.         Username:_________________________@power-net.net Password _______________________

Upon signing below you are agreeing to Power-Net Internet Services' Terms of Service- This is a pre-subscription form and service will not be immediately available. You will be contacted when service is available to set up a time for installation. If you have questions please contact your sales agent.

Signature____________________________________ Print Name______________________________ Date _______________

 Agent 

Action Communications
178 W. Wheatland
Remus, Mi. 49340
989.967.3229