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c/o mc.net
720 Industrial Dr. Unit 121
Cary, IL 60013
Customer Information
Name: _____________________________________________
Address: _____________________________________________
City: ________________ State: _____ Zip: ________
Phone: ________________ E-mail: ____________________
Payment Information
Payment Type: Credit Card _____ Check _____
Card Type: Visa ___ MasterCard ___ American Express ___ Discover ___
Card Number: ________________________________________
Card Expiration: ___________
Name on Credit Card: ________________________________
Service Information
Service Type:
Unlimited ($19.95/mo, $79.80/tri, $99.78/semi, $179.52/yr)
Timed x 5 Hour ($29.70/semi, $59.70/yr)
Timed x 20 Hour ($35.80/tri, $53.70/semi, $107.40/yr)
Unlimited - ChicagoSpeed ($39.80/tri, $59.70/semi, $109.44/yr)
Service Renewal: Monthly ___ Trimester ___ Semi-Annual ___ Annual ___
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