Nationwide (US & Canada) Internet Access Order Form
(Secure Order Form)

If you have any questions please call toll free 1.877.ESCAPE.NET -or- 1.800.985.HOST.
or 212-888-8780 (NYC residents) or e-mail info@escape.com.

Subscriber Information

  First Name
  		Last Name
 Address (Line 1)
  Company Name (if not applicable your name)
  		Address (Line 2)
  Phone
  --		 City  
  Fax
  --		 State/Prov.       ZIP
,
  E-mail Address 
  		Country

Account Information
Username  
Password (max. 16 characters)
Promotional Code (optional)
Payment Plan

The Monthly Plan is $19.95 per month, a total of $239.40 for one year of service.  Our One Year Special is a pre-paid plan in which you receive a 40% discount.  Total of $150.00 for the year, only $12.50 per month.

Where did you hear about Escape.net?

Method of Contact

E-mail    Telephone    Fax 

 

 

 Additional Information



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