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allcom.net On-line Registration
for Broadband DSL Service

Allendale Communications
6568 Lake Michigan Drive
Allendale, Michigan 49401
616-895-9911

Customer Name:
Account Number:
	Check your bill for your account number, or leave blank if you are a new customer
Address:

City:	State: Zip:
Contact Phone Number:
	You will be contacted to confirm set up and for your modem/router pick up.
Email Address:

Do you want to purchase a static IP?	no - no charge
	Yes - $10.00/mo.

Which modem / router do you need? (required)	Purchase 1 port Modem/Router Combo for $50.00
	Purchase 4 Port Modem/Router Combo for $75.00
	Purchase 1 port Bridged Modem for $50.00
	Have my own Modem/Router (Helpline charges may apply)

Is your computer?	Microsoft Windows
	Macintosh

Pay by?	VISA/Mastercard (An Allcom Representative will contact you)
	Automatic Deduction (An Allcom Representative will contact you)
	Add to my monthly bill

If you would prefer to pay in advance, call 616-895-9911 and talk to one of our
service representatives, they will be glad to help you.

Primary Username:

Your e-mail address is username@allcom.net.
Username and e-mail address is all lowercase.
Username should be 4 to 8 characters long.

Password:

Note: Password is made up of upper and lowercase letters. Password should be 4 to 8 characters long.

If the above primary username is already owned by someone, what is your second choice?

2nd Choice Username:

Comments:

If filled out by a Customer Service Representative, Submitted By:

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