Section A:

Choose a UserID (Maximum 8 Characters):
This will become your email address (ie: userid@autobahn.mb.ca). The first character should be a letter. Select up to 3 UserIDs in case the other two are reserved. Preference will be given in order listed.

Company Name (if applicable):

First Name:

Last Name:

Street Address:

City:

Province:

PostalCode:

Home Tel. (xxx) xxx-xxxx :

Bus. Tel. (xxx) xxx-xxxx :

Fax Tel. (xxx) xxx-xxxx :

Current Email Address:

How would you prefer to be contacted with your password and configuration parameters?

Section B:

Service Selection

*15 hours per month:

*45 hours per month:

*60 hours per month:

**Un-metered monthly:

*Package less than 360 hours/month require a credit card to be on file.
**Includes 3 additional email addresses
Excess hours are billed at $0.65/hour

Special Offer:
Get 1 month free, when you purchase 5 months of service (applies only to monthly option, not applicable on 15 hour packages).

I want to purchase 5 months and get the 6th Free:

The Terms and Conditions (located at http://autobahn.mb.ca/content/view/35), are applicable to this account. All clients must accept the Terms and Conditions inclusively, and agree to adhere to the Terms and Conditions during the duration of this contract.

Section D:

Credit Card Authorization

I authorize Autobahn Access Corporation to debit the following credit card each month equal to the monthly invoice for this account:

First & Last Name on credit card

Credit Card Number:

Expiry (MMYY):

CVV2 number*

Section E:

Acceptance of the contract in whole

By clicking on the "I Agree" button, you agree to the following:

1) The information you entered Section A is correct and you are the person listed as the contact.
2) You agree to the Terms and Conditions listed in Section C.
3) You authorize Autobahn Access Corporation to bill your credit card, as per Section D.
4) You accept this contract in whole as stated.