Internet Services
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1899 E. Wattles Rd. Troy, MI 48085 (248) 740-3400 Fax: (248) 740-0690
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We know that this appears inconvenient; but we have found that nothing replaces hard copy and a signature for the best protection of your privacy.
* New Account * Upgrade Services Order Form
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| Name | Requested Login (7 chars) |
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| Company | Desired Password (8 chars) |
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| Address | Return connection info by |
| | (circle one) Fax US Mail |
| | Email: |
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| City | Home Phone | Work Phone |
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| State | Zip | Fax | Referred by |
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Select desired payment method
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|* Discover/Visa/MC# Expires | Print cardholder name |
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| I authorize Msen to charge my Master Card/Visa/Discover account for all |
| charges for Msen service that I may accrue from month to month. This |
| authorization is valid until revoked in writing. |
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|Authorized Date: |
|Signature: |
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| Check (enclose setup and first month service fee with this form) |
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| PO (Business accounts only, please) | D&B# |
| # | (required for PO) |
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Select desired service level
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| * Personal Combo Account |
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| * Personal IP Account |
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| | * Shell Access via IP and personal web page |
| | * 75 additional hours per month of IP dialin access |
| | * Static IP address |
| | * Unmetered Modem Usage |
| | * ISDN access (circle one) 64K 128K |
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| * Personal Shell Account |
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| Select desired Personal Account options |
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| * Unmetered Modem Usage |
| * ISDN access (circle one) 64K 128K |
| * Email to pager service |
| * Domain registration |
| domain: |
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| * Business Account |
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| | Desired Domain: |
| | * New Domain * Existing |
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| | * 75 monthly hours of IP access |
| | * Secure web server |
| | * Daily www hit count report |
| | * Counter on web page |
| | * Unmetered modem usage |
| | * SMTP service and static IP for domain |
| | * Email to pager service |
| | * Static IP address |
| | * ISDN: (circle one) 64K 128K |
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| | * Email forwarding for additional domain |
| | domain: |
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| | * Attach additional domain to web page |
| | domain: |
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| | * uucp access for host |
| | hostname: |
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| Additional Information |
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| Signature: Date: |
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| Parent or Guardian (if under 18): Date: |
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| Please read and sign the attached contract |
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This Agreement is by and between Msen, Inc., duly authorized and existing under the laws of the State of Michigan with its main office at 1899 East Wattles Road, Troy, MI 48085 ("Msen"); and the Customer for the provision by Msen or its subcontractors of certain electronic communications services in exchange for the payment of fees and compliance with conditions stated herein.
Msen, Incorporated
PO Box 4725
Troy, MI 48099-4725
Fax: (248) 740-0690
Customer Signature: _____________________________________Date : ________________