Application Form for Internet Presence Service

Account name Address
City State or province
Country Phone number
Fax # Your 1st name
Last name 4-12 digits name wanted
MB of storage MB 6-8 digits Password wanted
Email 3-20 digits Email name

Print the agreement below, signed and Fax to us at 1 312 286 1992 you may also fax the credit card form or call us with the information at 1800 708 1016


This agreement, between EMERgency 24, Inc. and the Client, hereinafter referred to as Client. The purpose of this agreement is to set forth the terms for World Wide Web publishing space on the Internet by Client on EMERgency 24's Web server. Client is responsible for the content of its documents. Client will insure that no document contains obscene, pornographic, slanderous or any illegal material or information promoting illegal activity. Payment for the Client 's documents, is billed quarterly. Invoices will be sent by EMERgency 24 to the Client on or about the 5th of the month. Payment is to be made by Visa/Mastercard (automatic payment plan) or corporate check and is due by the 1st of the following month. Payments should be mailed to: EMERgency 24, Inc., 4179 W. Irving Park Road, Chicago, IL 60641-2906. Payment is considered late on the 10th of the month, and a late fee of three percent of the total amount due will be assessed. If payment is not received by the 15th of the month, Client 's documents are subject to removal from EMERgency 24's server. Signed: ________________________________________Title: ______________________________

Secure Credit Card Information

Credit card owner Card number
Card type Bank name
Expiration date Billing address
City State or Province