Web Express, Inc. Center for Web Hosting, DSL and Corporate VPN Services

Nationwide DSL Order Form

Web Express would like to welcome you as a customer. In order to help you understand your new service, here are answers to some questions commonly asked by new customers. In addition to reviewing this document, it is very important that you read all of your Service Agreement. Once you have reviewed this material, we will be happy to explain any portion of your agreement or answer your questions.

Your Agreement

By submitting this order form, you’re agreeing to the Terms and Conditions set forth in the Service Agreement. So, please make sure you read the Service Agreement carefully before submitting your order. Your agreement for service with WebEx begins when we receive your order online or a signed copy of agreement by fax or mail. Billing begins when the service is installed. You must accompany with your order a deposit equals the total startup charge before online rebates.

Customer Information

Name:
Company Name:
Company Address:
City, State, Zip:
Service Address (if different):
City, State, Zip:
Telephone Number:
Fax Number:
E-Mail :
Pager or Mobile Number:	(For alarm notification)
E-Mail Address:
Contact Person:	(If different)
Service Plan:
Deposit :

Billing Information:

Billing Info if different from the customer info

Billing Name:

Billing Address:

Billing City, State, Zip:

Telephone Number:

Additional information as needed or as available