Instant Access Customer Application
This form must be completed in full before the activation of any services.

Instant Access Customer ID ______ Application Date _________

Company Name ______________________
Address ______________________
Address ______________________
City ____________________ State _____ Zip ________

Contact # 1 (Overall account administration, information, technical support, etc.)

Name __________________________ Title ________________________
Email Address _______________________ Signature ________________________
Contact Phone ___________________ Contact Fax ___________________

Contact # 2 (Contact for Accounts Payable)

Name __________________________ Title ________________________
Email Address _______________________ Signature ________________________
Contact Phone ___________________ Contact Fax ___________________

Note to Customers: Persons not appearing on this form will not be allowed contact with Instant Access regarding this account. Instant Access maintains strict account security. Therefore, the person whom ISP desires to have contact with Instant Access Personel should be added to this form.

Instant Access, Inc. Internal Use

Accouting Username ________________
Accouting Password ________________
Account Created Date ________________
Account Created By ________________
 The Instant Access Accouting Username is used for deposit and managementof all Instant Access Customer Services. This will be used in conjunction with all customer contact. This username and password is also used to access the online Instant Access Account Management Web Site.

ALL INSTANT ACCESS SERVICES ARE HELD TO THE INSTANTACCESS TERMS OF SERVICE DOCUMENT AND THE INSTANT ACCESS WHOLESALE SERVICE AGREEMENT

Post Office Box 6672, South Bend, IN 46660
(574)259-6687 Voice, (253)541-4837 Fax
sales@instantaccess.net