Family Entertainment Network
1123 S. Broadway
Pittsburg, Kansas 66762
Please print out this form and either 1) Mail it, along with $14.95 for your first month of service, or 2) Bring it into our store at 1123 S Broadway, Pittsburg, to sign up for internet access at FEN. Or if you'd prefer, you can e-mail us at: sales@fament.com with all your pertinent account information and someone will contact you about payment information.

Today's Date _________________________

User Name_____________________________________
Should be 3-30 characters, will become part of your e-mail address if you are not a Web-TV customer (username@fament.com) - No spaces or punctuation marks allowed, will be entered in all lower case letters

Password _______________________________
3-10 characters - it is recommended that this be an alpha-numeric combination that is disassociated from you in every way. No spaces or punctuation marks.

I will use (please check one):
_____PC (Win95/98/NT/2000/XP) _____Macintosh _____Web-TV

My Web-TV E-mail address: __________________________

Type of Account:
____ Personal                                  ____ Business

Account Information:
Name _________________________________________

Address _______________________________________

City ____________________________________

Home Phone: ____________________________

Bills will be sent via e-mail unless otherwise requested
____ Send my bill via postal mail (check if yes)

Bill To: (ONLY if different from above)
Name _________________________________________

Address _______________________________________

City ___________________________________________

State _______________________ Zip ______________

Thank You for Your Business