
Gateway to the Universe
REFERRAL CARD
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Using your web browser's print function print this form and fill the first part out completely. Then give it to a friend or family member who is interested in internet access. When they send in the form with payment in full for internet access, you will receive a $10.00 Check.
Fill in your current customer information.
Last Name_______________________ First Name_______________________
Company Name____________________ Username_______________________
Mailing Address____________________________________________________
City__________________ State___________________ Zip Code___________
(Area Code)________ Phone Number__________________________________
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New referred customer application
Requested Username_______________________ Password_______________
Last Name____________________ First Name__________________ MI_____
Company Name____________________________________________________
Mailing Address____________________________________________________
City__________________ State___________________ Zip Code___________
(Area Code)________ Phone Number__________________________________
Amount Enclosed:
|__| $24.95 Monthly |__| $69.95 Quarterly |__| $124.95 Semi-Annually |__| $214.95 Annually
|__| Macintosh |__| Windows 3.1 |__| Windows 95 |__| Other_________
For Webhosting referrals please call.
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