County:	- Please Choose a County -
City:	- Please Choose a City -
Package:	- Packages Available -
Profile Information:
First Name:
Last Name:
Company:
Address:
City:
State:	Zip:
Phone:
Alt. Phone:

Current Email Address:
How Did You Hear About Us?
------------ Select -----------  A Business - Please specify  A Genext Customer--please specify  A Genext Employee--please specify  Christmas Card  Community Event  Home Show  Nickel Ad  Coupon  Direct Mail  Friend--please specify  Print Ad--please specify  Phonebook  Radio--please specify  TV Ad --please specify  Website  BNI Referral  Other--please specify

Account Information:
Choose Your Email Address (Username).
1st Choice:	@genext.net
2nd Choice:	@genext.net
Choose Your Password.
1st Choice:
2nd Choice:
(Password must be 5 to 8 characters: Alpha-Numeric only)

Activated on  or Right away. [?]

I would like set up help on - or -

I can do myself.

Billing Options:

-- Select --   Genext Email   Other Email   Autopay **   Hardcopy  --------------  Other Email:

** Autopay Requires Authorization Form

System Information:

What Type of Operating System Do You Run?

--------- Select ---------  Windows 95/98  Windows 2000  Windows NT  Windows ME  Windows XP  Macintosh  Other

General Comments:

I accept the user policy.

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