Name:______________________________________
Login name:________________@mo-net.com (This will be your e-mail address)
Sign-on Password:______________(Minimum 6 characters, at least one number)
Street Address:____________________________
City:_____________ State:_____ ZIP:_________
Voice Phone Number:________________
Driver's License Number:______________________(For account verification)
Business or Daytime Phone:_________________
Business Name:_____________________________

I have read and agree to the terms of the Agreement. I understand that Mo-Net, Inc. may suspend or terminate access to my account(s) in the event that any of the information I supply to Mo-Net, Inc. is found to be false or, if I breach any of the term s of this Agreement.

Payment Option:
Monthly_____($14.95) Annual_____($165.00)
(Please add $5.00 for New User Setup.)

If you wish to pay by credit card, please provide the following information:

___VISA ___Mastercard ___Discover

Card Number:______-______-______-______ Exp___/____

Your card will be automatically billed on the first day of each month.

___________________________
Signature

______________
Date

Please print and complete this form and return with payment to: