Please provide the following information, Red* indicates it is required:

Company Name
*Name
*Street address
Address (cont.)
*City
*State/Province
*Zip/Postal code
Country
E-Mail Address	if you already have one!
*Requested E-mail Address Please choose 3 options in case yours is already taken	@lifegrid.com (1st choice) @lifegrid.com (2nd Choice) @lifegrid.com (3rd choice)
Password
*Internet Access	Regular Access Special $14.95 per month with no setup fee! Regular Access 1 year pre-paid $120 (equals $10 per month) Night/Weekend Access $9.95 per month plus $9.95 setup Night/Weekend Access 1 year pre-paid $95.95 (equals $7.99 per month) 64k ISDN Access $24.95 per month plus $24.95 setup 128k ISDN $49.90 per month plus $49.90 setup
Extras	Extra E-Mails $4.95 per month each (please list names in notes)
Notes or Special Instructions
*Credit card	VISA MasterCard Discover American Express
*Cardholder name
*Card number
*Expiration date
*CVC code	click here for more info
	Billing address for Credit Card if different from above.
Street address
City
State/Province
Zip/Postal code
*Phone	please include area code!
Once you fill out this form, you will INSTANTLY be given a username and password, and instructions to access the internet. Please be sure you are making a local call, LifeGrid will not be responsible for ANY long distance charges incurred.