Please sign and Fax form to: 847-480-9715
And be sure to fill out our promotion form.
Check here for domain name availability.

MicroWeb Technology Inc. Account Application

I confirm that I have read and agree to all terms and conditions set forth in this document and further agree to purchase one of the services indicated below.

Authorized Signature: ___________________________           Date: ___________


Title: ____________________________

Company Name: ____________________________________

Contact: _________________________________________  Phone: _______________

Address: _________________________________

Adress:  _________________________________


City: _________________________   State:_________    Zip: ___________

Phone:__________________                FAX: _______________________


Domain Name__________________________.  Please give two choices for a
Domain Name, (consists of the rightmost word after the "@" symbol in the
email address ending in .com for commercial or .org for organization.  This
name may include a hyphen.  Numbers and symbols may not be used.)  All
attempts will be made to get your first choice.
You can check for Domain Name availability using this form.

1) _________________________ . com

2) _________________________ . com

I am enclosing a check or money order in the amount of $ ____________*
payable to MicroWeb Technology, Inc.

Send Completed Form and Funds Made Payable To:

                      MicroWeb Technology, Inc.
                      PO Box 2384
                      Northbrook, IL 60065-2384


Date: _________ by _____

* See MicroWeb Technology, Inc. Rates and Services Sheet for details.

©Copyright MTI, Inc., 1996

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