COMPLETE FORM, PRINT, SIGN, DATE, and
SEND COMPLETED APPLICATION TO:

Hawaii Information Service
680 Iwilei Road Suite 777,
Honolulu, HI 96817
Tel: (808) 599-4224
FAX: (808) 536-6499
Digital Subscriber Line Application
CONTACT NAME
COMPANY NAME
ADDRESS
CITY
STATE
ZIP
PHONE
FAX
 Phone line that DSL will be set up on:
EMAIL
E M A I L     U S E R N A M E     S E T U P
Email will be username@HawaiiInformation.net
USERNAME: 2-8 characters
PASSWORD
BEGIN SERVICE DATE
ADDITIONAL USERNAMES

PASSWORD

BEGIN SERVICE DATE

D S L     O N E - T I M E     F E E S
INITIAL SETUP FEE (Includes 1 Static IP Address or Multiple Virtual IP Addresses) $75.00
 
D S L     M O N T H L Y     F E E S
LEVEL OF INTERNET SPEED (Check box for level desired and enter fee amount)
     BRONZE PLUS (768Kbps in / 128Kbps out) $49.00
      TBA (1.5Mbps in / 128Kbps out) $99.00
      SILVER (384Kbps in / 384Kbps out) $149.00
      TBA (1.5Mbps in / 384Kbps out) $199.00
      Gold (768Kbps in / 768Kbps out) $279.00
ENTER MONTHLY FEE HERE:  
D S L     O P T I O N A L     S E R V I C E S
DESCRIPTION PRICE FEE CALCULATION AMOUNT
1 Internet Dial-up Acct. (for home or travel) $0    
   + per additional dial-up account (for employers) $17.95/mo. Monthly fee x  

Domain Name Hosting Service $125.00 One-time setup fee
(w/Internic registration)
 
(E-MAIL: you@yourcompany.com
WEBSITE: www.yourcompany.com)
$10.00/mo. Monthly fee
(Note: 1st 5 megs are free)
 
+ per additional 10 megs of website hosting $10.00/mo. Monthly fee x  

GRAND TOTAL
(Initial set-up fee [$75] + DSL Monthly Fee + Optional Onetime and/or Monthly fee[s] )
 
B I L L I N G     I N F O R M A T I O N     NEW CUSTOMER     EXISTING CUSTOMER
NOTE: New customers are required to pay by Mastercard or Visa
Charge Number Expiration MO YR
Name on Card
Authorized Signature ___________________________________________
A U T H O R I Z A T I O N
I agree to pay the above total monthly fee in advance of the month of service. I understand that there is no proration for partial months, nor any refund for discontinuing service prior to the end of the month. I have read and agree to abide by the Terms and Conditions Policy. I also understand that if I discontinue service and thereafter resume service set-up charges will be reassessed.
Signed _____________________________________ Date ________________
THIS SECTION IS STAFF USE ONLY:
ACCOUNT NUMBER
 
DLCI NUMBER
 
IP ADDRESSES:
 
2
 
3
 

 

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