Internet User Account Application
Please provide the following contact information:
Name Title Organization Street Address Address (cont.) City State Zip Code Work Phone Home Phone FAX Best Time to Call Current ISP E-mail Address
Please select a monthly service plan:
$14.95 Monthly $179.40 Annually
For any other needed services or Technical Support, please call Ceva.net at 1-715-204-9423.
Choose one of the following payment options:
Credit Card Checking Account Debit/Bank Draft
Please provide your account information:
* Only the Primary User-ID can be used to connect to the service.
Please provide one of the following items of information to identify you for account verification purposes:
SSN DOB DL# DL State Maiden Name Secret
How did you hear about Ceva.net?
Newspaper Radio Current Communicator Direct Mail/Brochure Friend or Ceva Customer Other
If you checked Friend or Ceva Customer, please tell us their name:
If you checked Other, please tell us more:
To complete your sign up please choose one:
I will call Ceva.net at my earliest convienience toll-free at 1-715-204-9423
I would like Ceva.net to call me back during the hours I specified above.
Applicant Signature:__________________________________________________
This form can be filled out on-line, when finished either click on submit or print and mail the form to Ceva.net at:
TruTechnology LLC (dba CEVA.net); P.O. Box 38; Boyd, WI 54726
By clicking on Submit you are doing the same as signing this form.
DO NOT forget to print a copy of this form for yourself!