TLC Internet Services ... New Dial Up Account Request

Sign Up For An Internet Account

	* Required Fields
* First Name:
* Last Name:
Company:
* Address
* City:
* State:
* Zip:
* Home or Main Phone:
Work Phone:
Mobile Phone:
* Email:
* Account Type
Pick User name	Type the username you would prefer. If it has not been taken this will be your login and email. Please choose at least 1 alternative.
* Preferred Username 1:
Preferred Username 2:
Preferred Username 3:
Password	Type a password in the field below. Use between 4 and 15 characters with not spaces.
Type password here:

Referred by a friend? If so give them a month of free internet by telling us who (name, home phone):
Best time to call you:
To better serve you we will need complete and accurate information. Please review your information then click the submit button. If you have problems with this form click here to go to our contact page. Accounts are typically setup within 24 hours. You may stop by our office between 9am and 5pm M-F to make your initial payment or you may call us with your credit card info. Initial payment must be made within 2 business days for new account to remain active. Note: Credit card will only be used for the initial charge. You will receive a monthly bill via the usps. By clicking the 'submit' button below you accept the terms and conditions set forth on our policies page.

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SERVICE

New & Used

735.2502

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