New Subscriber Sign Up Form - via Fax

 

Thank you for choosing Purespeed!

Instructions - You may either a) Print this form and complete the information requested, or b) Type the information in this form and then Print it.  Once complete, you may send it to us either via fax or mail.

 

Fax to:

301-668-7004

Mail to:

 Purespeed 

8 East Second Street

Frederick, MD 21701

 

A Customer Care representative will establish your account and then contact you to assist you in getting on line!

 

Customer Information Please select a username and password.  
First Name User Name @purespeed.com
Last Name Password
Street Address Confirm Password
Address (cont.) The User Name you select will also be your initial email address. If you want a different email address, contact us.
City
State/Province

Choose one of the following options 

(Mark with an X):

Zip/Postal Code

Monthly at $17.95
Country
Annually at $167.40 ($13.95 per month)
Work Phone
Two-Years at $300.00 ($12.50 per month)
Home Phone Six Months at $97.70 ($16.28 per month) 
FAX Three Months at $49.95 ($16.65)
E-mail

Credit Card Payment Information:

Credit Card  (Mark with an X):      VISA     Mastercard     American Express 

Cardholder Name
Card Number
Expiration Date

I prefer another method of payment or I prefer to give my credit card number over the phone, please call me at .

I intend to use this account as (no difference in price): Please Contact Me About My New Account:

Personal Account Call me at Home
Business Account Call me at Work
Both Contact Me via Email
Send me a Letter
If Yes (Mark with an X) Additional Options: Send me a Fax
Would you like Additional Email Accounts in addition to the 4 you receive as part of your subscription? I Want My Service to Start On:
Do You Wish to Establish a Personal Web Page?

-- mm/dd/yy

Any Additional Information You Wish to Tell Us?

Select 'File' from your browser menu and then 'Print' when you are ready to print this Form.