********* PRINT THIS FORM FOR FAX OR MAIL **********

EZNET Total Access
Attention: Billing
848 4th Ave, 3rd. Fl
Huntington, WV  25701

Fax: (304) 525-3772                              


Commercial Account Employee 
Employment Verification Form

Your company has entered into an agreement with EZNET to offer ALL its
employees Internet access for the outstanding value of $15.00 per month.

Your coordinator must sign the coupon before EZNET can provide the CAE discount.

Date: ___________

Company Name: ________________________________  Account Number: ______________

First Name: ___________________________ Last Name: ___________________________

Address: __________________________ City: _________ State: ____ Zip: _________

Home Phone: ______________ Work Phone: _______________ Fax: _________________

Coordinator (Signature):_____________________________________________________

Coordinator (Print Name):____________________________________________________

In order to create your new EZNET account, we will need for you to pick a Username and
a Password.

There are certain rules for your username and password: 

1) Your username and password can be from four to eight characters long.
 
2) They must begin with a letter, not a number.
 
3) All letters must be lowercase Underscores '_', dashes '-', quotes, double-quotes and
other non-letter characters "!@#$%^&*()=+{}|\][:;?></" are not allowed. 
														 
The username and password that you choose today will also serve as your login ID. Your
password needs to be unique. You cannot use pass, password or your username as your
password. 

Login:
Username: ____________________ Password: ___________________	
			
Second Email (Optional):
Username: ____________________ Password: ___________________

Third Email (Optional):
Username: ____________________ Password: ___________________

Fourth Email (Optional):
Username: ____________________ Password: ___________________