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Personal Systems Plus, Inc. |
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| Startup Date | Referred By: |
| Name | |
| Company | |
| Address | |
| City, State, Zip | |
| Area Code & Phone | Other Phone |
| Fax Number | |
| Logon Name | Password |
| Addt'l Email Names: | Password |
| Password | |
| Password | |
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Standard Dial-Up Service $20.00 / month (plus county sales tax) |
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| (6) Months Prepaid by
Check. Make all checks payable to Personal Systems Plus, Inc. (plus county sales tax) |
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| Customer Signature | Date |
| Monthly Payment by Charge Card (circle one): 1st of Month 15th of Month | |
| Circle card type | Amex Discover MasterCard Visa |
| CC Number | Expires |
| Name on Card | Security# |
| Authorized Signature | Date Signed |
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