SEND TO: 710 AUSTIN ST, LEVELLAND, TX 79336 (806) 894-4932

(Print, fill out and mail to HORIZONZ [above] )

Dial Up Customer Information DATE: _________________

Full Name: ___________________________________________________

Address: ______________________________________ City: __________________ St: ______

ZIP Code: ________ Home Phone: ( ) ______________ Work Phone: ( ) ______________

Username: _________________________________ Password: ____________________________

( 3 – 15 lower case characters) (6 – 15 lower case characters)

SUBSCRIPTION OPTIONS
Monthly Non-Filtered	$15.95	PAYMENT METHOD
Monthly Web ACCEL	$ 2.00	Choose One		Accounts with payments not received by the due date will be suspended until paid. Accounts past due more than 5 days will be closed until paid.
Monthly E-mail (additional each)	$ 2.00	Cash/M. O./Check:
		Credit Card:
Monthly Filtered	$19.95	Bank Draft:
Web ACCEL NOT available	--------
Monthly E-mail (each)	$ 2.00	CREDIT CARD AUTHORIZATION
		I authorize HORIZONZ to charge my credit card monthly [ ] or annually [ ] for Internet service.
Annual Non-Filtered:	$156.00
Annual Filtered	$210.00	Please PRINT LEGIBLY
		Name on Card:
Non-Filtered
Semester Special (4 months)	$54.00	Type of Card:	VISA [ ] MC [ ] DISCOVER [ ]
Filtered		Credit Card #:
Semester Special (4 months	$72.00	Expiration Date:
To qualify for the Semester special, we require a copy of your current Student ID, class schedule or other documentation proving that you are a CURRENT college student.		CVV2 Number:
		Authorized Signature:

BANK DRAFT AUTHORIZATION

I hereby authorize Horizonz Internet, hereinafter called "HORIZONZ", to debit my checking account at the financial institution named below.

PLEASE ATTACH A COPY OF A VOIDED CHECK TO THIS FORM.

This authority is to remain in full force and effect until I have given written notification of it's termination to Horizonz in such manner as to afford Horizonz and my financial institution a reasonable time to act upon it. I further understand that if at any time this authorization is not honored by my financial institution, and is returned to HORIZONZ unpaid, my Internet service is subject to disconnection without further notice. I authorize ALL monthly invoices to be paid using the checking account information on a recurring basis including any current amount due.

Bank Name: _________________________________ Account Name: __________________________________

Routing Number: ______________________________ Account Number: ________________________________

Authorized Signature: __________________________ Amount to be charged: $___________________________

I agree to the following policies:

-Horizonz must receive notice of cancellation in writing by mail or by fax, or it may be emailed to admin@horizonz.com. In any case notice must be received at HORIZONZ before the last day of the month or you will incur a TEN-DOLLAR ($10.00) late cancel fee.

- All cancellations and any associated refunds will be effective on the first day of the month following the date of receipt of proper cancellation notice.

-Refunds will be assessed according to the amount of time service was active. This amount may be different from the term paid depending on the actual time the service used.

Date: _________________________________Signature: __________________________________________________