Computer Visions, Inc.
National Internet Online Request Form

Please provide the following contact information:

Account Name
Mailing Address
City
State		Zip Code
Home Phone		Current E-mail
Alternate Phone		Specify:	Work Cell Other
Drivers License/SS Number		Specify:	Drivers License Social Security

Please provide your account information:

Login User Name	@cv.multidial.com
Password		Confirm Password
1st Email	@cvamerica.net
Password		Confirm Password
2nd Email	@cvamerica.net
Password		Confirm Password
3rd Email	@cvamerica.net
Password		Confirm Password
Alternate Login User Name	@cv.multidial.com

Please provide the following billing information:

Billing Type	Email Billing Credit Card Billing
Billing Option	Monthly Quarterly Bi-Annual Annual
Preferred Billing Email
Credit/Debit Card Type	Not Applicable Visa Master Card *Must include Visa or Master Card information for Credit/Debit Card Billing Option
Card Number
Expiration Date
Name on Card

Disclaimer Information:  There are no guarantees that the requested username or emails will be available.  Any information posted on the web space provided by CVAmerica is not the responsibility of CVAmerica, but instead the responsibilities of the user which posted it.  CVAmerica holds the right to disconnect the user at any time.  Any illegal use of the Internet through CVAmerica will result in immediate disconnection and prosecution.  I also understand and agree to the following Logon limitations:  CVAmerica.net unlimited access does not mean dedicated access!  I understand that all end-users that are logged in and have no activity (are idle) for 20 consecutive minutes, will be disconnected from the service.  Use of a ping or "keep alive" program, auto-emailing, or any other means to circumvent this process by any end-user is strictly prohibited and may result in account being terminated due to abuse!  The determination of what abuse is shall be at the sole determination of Provider.  I further understand that there is also a mandatory 4-hour continuous use session limit.  This means that if an End-user is online for a continuous period of 4 hours, End-user is subject to an auto disconnect.  End-user may immediately dial back into the service after either type of disconnect.  Provider reserves the right to adjust these limits or include additional limits as Provider feels is necessary to maintain network integrity.  I understand that if my account becomes past due there will be a $1.00 Late Fee applied and if my account becomes delinquent to the point that CVAmerica terminates my service due to non-payment, there will be a $10.00 Disconnect Fee added to my account and Computer Visions, Inc. will report me to various credit agencies, Plus I will be responsible for any and all recovery fees.  I also understand if I pay by check and my bank account for any reason does not honor any check, I will pay in cash the bad check plus any applicable service fees.  I understand that any changes to the Email addresses on my account are subject to a $2.00 charge per incident.  I am aware that CANCELLATION or ANY CHANGES TO MY ACCOUNT MUST BE DONE IN WRITING WITHIN 5 BUSINESS DAYS PRIOR to BILLING.  A change form will be available in the office (emails to billing@cvamerica.net from customers personal email will be accepted); otherwise CVAmerica will consider my account still valid and unchanged.
 I hereby agree to the Terms and Conditions of this agreement, and understand that entering my name below and submitting this form is a legal and binding contract with CVAmerica.net:

Enter your digital signature and the date of signup request:

      
               Type your full name above as an electronic signature                  Date -- mm/dd/yy