15340 San Fernando Mission Blvd

Mission Hills, CA 91345

Voice: (805) 295-6824 - FAX: (818) 837-3165


I authorize JLM Internet Services to charge my credit card listed below on the first day of each billing period, (billing periods begin the following day of the accounts activation) the monthly fee for the use of an Internet access account supplied by JLM Internet Services. Bi-Annual and Annual accounts will be billed in full. For payment by check, monthly accounts will be billed for a calendar quarter, with payment in advance. If paying by check, I will mail my check for the subscription fee so that it reaches JLM Internet Services no later than 3 days prior to the start of the new billing period . I understand that account cancellation requests will only be processed by JLM Internet Services at the end of the billable period. If I wish to terminate my account at the end of the current billable period, JLM Internet Services must receive my e-mail or written request at least 3 business days prior to the end of the current billable period. Otherwise, my account will be terminated at the end of the next calendar month and my credit card will be charged the monthly fee and the cost of any excess disk storage space during the additional month. JLM Internet Services may waive the 3 business day notice at it's own discretion. I have received and read a copy of the Additional Terms and Conditions of JLM Internet Services, and I accept the Additional Terms and Conditions. I accept the above terms and conditions of usage for an Internet Access Account from JLM Internet Services.


ACCOUNT TYPE* (please circle one):

Monthly Account Bi-Annual Account Yearly Account Other Accounts
$17.95* $15.95** $13.95** Call for Details

*$15.00 Setup Fee
** Cost per month

UserID - A UserID should be a name that will identify you and will be easy for you to remember. Since our system is case sensitive, you will need to enter the UserID in all lowercase letters. The UserID should be at least 5 characters but no more than 10 characters. Please submit 3 choices. We will notify you of which choice we used. If we have already assigned you a UserID, please enter it here. This ID will also be used as your first email name.


1.____________________ 2.____________________ 3.____________________


2nd E-Mail Name - Please submit 3 choices for your 2nd e-mail account. We will notify you of which choice we used.


1.____________________ 2.____________________ 3.____________________


Passwords - Since our system is case sensitive, you will have to enter the Password exactly as you put it on this form:


1st Account __ __ __ __ __ __ __ __ 2nd Account __ __ __ __ __ __ __ __


Please print name and address of account subscriber:


FIRST NAME ______________________MIDDLE INITIAL ______


LAST NAME ____________________________________________


Street Address _________________________________________________


City: ________________________________________ State: ________________


Zip Code: _____________ Home Phone: (______) ________________


Work Phone: (______) ________________






Payment method to be used (please circle one):


MasterCard  VISA  Discover  American Express  Check


Credit Card No: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __


Credit Card Expiration Date (Month/Year): ___ ___ / ___ ___


Name as it appears on credit card (please print):




Phone: (_____) ______________


Signature:_____________________________________ Date:_______________