Dialup Internet Order Form

Grapevinenet Works Dialup Internet & Web Hosting Order Form

Please print out this Form, fill it out and mail it to:

Grapevinenet Works ~ 6434 Old Redwood Hwy. ~ Santa Rosa, CA 95403-1158

Name: _________________________________________________
Address: _______________________________________________

_____________________________________________________
City: ___________________________________________________
State: _____ ZIP: __________ Phone: _________________
E-mail address: __________________________________________
Dialup Rates: $14.95 / month $15.95 / month $16.95 / month
(See our website for detailed information.)
Realm: ______________ Web Accelerator: $3.00 / month _____
Hosting Package / Rates:    Barbera: $3.95 / month + $5.00 setup charge.
  Chardonnay: $7.95 / mo.    Merlot: $14.95 / mo.    Resling: $19.95 / mo.
  Sangiovese: $29.95 / mo.    Viognier: $39.95 / mo.
  Zinfandel: $49.95 /mo.   Dedicated IP: $2.00 / mo. + $10.00 setup charge.
Hosting Package: _________________ Dedicated IP: ______
Referral Code: __________ Software Bundle: _____________
Monthly (Credit Card): _____ Annual (Check / MO): ________
VISA    ___    MasterCard    ___    Discover    ___    AMEX    _____
Card Number:    _________________________________________
Card Code (3-digit):    ______    Exp Date:    __________________
Signature:    ____________________________________________