Use this form to request an Internet Access account
with Cooperative Resources.

PERSONAL INFORMATION

First Name    Last Name    Billing Address    City    State    Zip Code    Home Phone    Work Phone

USER INFORMATION

E-mail/Log-on name  [** 3-12 lowercase ** ]  [* letters or numbers *]  [*NO slashes, NO dashes *]  [*NO symbols or underlines*]  Password  [*** 6-12 lowercase *** ]  [** letters or numbers **]    [*NO slashes, NO dashes *]  [*NO symbols or underlines*]

COMPUTER INFORMATION

Please Check Which Are Present on Your Computer. (Check All That Apply)    IBM Compatible    Windows 3.x    Windows 95    Netscape - - - - - - version #      Macintosh    Other    Windows 98    Internet Explorer - version #

PAYMENT INFORMATION

Payment due on or before the 15th of each Month. Choose your billing preference from one below.    Check        Cash         E-Mail Bill Reminder          Visa    Amex    MasterCard

SUBMIT FORM

By submitting this form, you hereby apply for membership in the Cooperative Resources, Inc., and for the products and/or services therefore subject to Terms and Conditions of Cooperative Resources, Inc., in effect at the time of delivery. As a member of Cooperative Resources, Inc., you agree to be bound by it's Articles of Incorporation and Bylaws(copies are on-line).