--------Earthnet Account Application Form---------
                 Please fill this form out and fax to: (XXX) XXX-XXXX
             (or mail to: 5717 Arapahoe Road, Suite 4, Boulder, CO  80303)


   Last Name: _________________________________   First Name: _____________________
   (person responsible for billing)

   Name of business, if applicable: _______________________________________________


   Billing address: _______________________________________________________________


   City: _____________________________________  State: _______   Zip: _____________


   Phone(wk): _________________ Phone(hm): __________________ Fax:_________________


   Username: ______________________
   Your username must begin with a letter, be at least three characters, no longer
   than eight. You can't use any symbols in your username, only letters and numbers.
   It must be all lowercase.  Your e-mail address will be [username]@earthnet.net

   Password: ______________________
   Your password should not be easy to guess, but easy to remember. It must be a
   minimum of six characters long, and include at least one letter.

   How did you hear about us or who (username) referred you?

   _________________________________________________________________________________

   Computer Type (PC, Mac, other) and OS/version (Win95, Win3.1, MacOS 7.5, etc)?

   _________________________________________________________________________________

   Account Type (see Services info. http://www.earthnet.net/services.html)

   _________________________________________________________________________________

   Other Services needed (Domain Name registration, Dedicated URL, etc...)

   _________________________________________________________________________________

   _________________________________________________________________________________

   Receive a $2/month discount for paying with credit card or automatic debit.  Pre-
   pay 6 months and receive 1 month free (excludes extra hours). Pre-pay 12 months,
   receive 2 months free (excludes extra hours).  Method of payment (checkone):

   Invoice _____   VISA ______   Mastercard ______   Discover ______   AMEX ________

   Credit Card # ______________________________________   Expiration Date: _________