Digital Subscriber Line, DSL, Application Form: Hawaii Information Service Products and Services - real estate, property listings, multiple listing service for hawaii, public records, parcel maps, business registrations, professional and vocational licenses, digital subscriber lines

	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

Hawaii Information Service
www.HawaiiInformation.com