EBTC Internet/DSL Registration Form
Type of Account Individual Business
Name: __________________________________________________
Address: __________________________________________________
___________________________ State: ___________ Zip:_________
Home Telephone (_____) _______________ Work Phone: (_____)______________
Preferred Username: _____________________________(15 characters or less)
Social Security # ___________ - ___________ - ___________
Shared Secret : ___________________ (For password security)
Date of Birth ______/______/______
Registration cannot be processed if the above is not filled out completely
PACKAGES: Check all services for which you are applying

DSL Service--        

                      Unlimited Choices


                      _____   5Mbps/1Mbps ($ 44.95/mo.)

                      _____   10Mbps/1Mbps ($ 54.95/mo.)




DSL Modem - Purchase ($69.95)  Rent ($10.00/mo.) Wireless ($89.95)  Rent ($15.00/mo.)

DSL Installation Charge - $49.00 (one time charge)
Free Additional Email Accounts
You can choose to have up to 4 additional email accounts at no additional charge. You are not required to use any additional usernames. usernames need to be 15 characters or less.
1st Additional Username: ____________________ Real Name: ______________________
2nd Additional Username: ____________________ Real Name: ______________________
3rd Additional Username: _____________________ Real Name: ______________________
4th Additional Username: _____________________ Real Name: ______________________
Additional Email Boxes
$5/mo. per mailbox. Usernames need to be 15 characters or less
5th Additional Username: _____________________ Real Name: ______________________
6th Additional Username: _____________________ Real Name: ______________________




Please indicate system type by circling: WIN 3.1 not supported
Windows 7 Windows XP Windows 8
Macintosh VISTA Windows 2000
           *SecureIT Plus Support for Windows 98 and Windows ME will cease at the end of 2008.

A signature is REQUIRED to process your order. Your signature below indicates acceptance of the billing terms and the netINS "Terms and Conditions" (below).


Signature: ____________________________________ Date: ______________________

Return to:
East Buchanan Telephone Cooperative
214 Third Street North
PO Box 100

Winthrop, IA 50682-0100
FAX: (319) 935-3010

Terms and Conditions

1. By signing this registration form and agreement, you (customer) agree to the following terms and conditions of the service described below.

2. These services are provided by netINS, 4201 Corporate Drive, West Des Moines,IA, 50266-5906.

3. Telephone technical support (800-205-1110) is available upon activation of your account.

4. INS make no express or implied warranty of any kind. There is no express or implied warranty of merchantability or fitness for a particular purpose for the services to be provided by netINS. netINS makes no attempt to verify accurate receipt of any message and is not responsible for any loss of data resulting from delays, non deliveries, incorrect deliveries or service interruptions, including those caused by the negligence, errors, or omissions of netINS, nor for consequential damages regardless of their cause.

5. Customer agrees to comply with the terms governing use of the netINS network, as they may change from time to time. Any changes to the terms governing use of the netINS network will be posted as warranted on the netINS computer system. http://netINS.net/policy/

6. This agreement shall be governed by and construed in accordance with the laws of the state of Iowa applicable to contracts to be performed entirely within the state.

7. Either party may terminate this agreement at any given time by giving written notice. Such notice is effective when given. Customer is obligated to pay for service through the termination date, as detailed on the final invoice.

8. By accessing and using the netINS computer system, user is consenting to system monitoring for law enforcement and other purposes. Unauthorized use of, or access to, this computer system may subject users to criminal prosecution and penalties. User agrees to indemnify netINS against liability for any and all use of user's account.
Also see "Acceptable Use Policy" at www.eastbuchanan.com/internet/acceptableuse.htm
Also see "Network Management Policy" at www.eastbuchanan.com/internet/networkmanagement.htm


East Buchanan Telephone Cooperative is an Equal Opportunity Provider.