Panix, New York's first Internet Service Provider

Panix Personal DSL Order Form

Please do not fill out this form until you are ready to place an order. Submission of this form is an agreement to purchase ADSL service with a minimum one-year commitment with Panix, and you will be billed. By submitting, you also agree to be bound by the Panix Personal DSL Terms of Service, so please read them before ordering. Payment is due upon install completion.

If you have any questions, please send email to adsl@panix.com.

Installation Information

To speed processing of your order, please enter address information exactly as it appears on your telephone bill.

*Your name:

*Street address:

*City, *State, *Zip:
, -

*Installation phone number:
( ) (This phone must be the landline phone to be used for the DSL service at the site

*Your email address:

*Your daytime phone number:
( )

Your evening or cellphone number:
( )

How would you prefer that we contact you?

Type of building:

Telephone box location:

Panix Personal DSL now comes in six speed combinations
Which speed would you like?

Panix requires you to use Covad-supplied ADSL equipment with new Personal DSL orders. If you have a suitable ADSL equipment from a previous Covad ADSL connection, you don't need to buy a new one, but please tell us what model you have. Please also keep in mind that we can't provide warranty replacements for modems not included in the order.

Email address

Choose a username for your "maintenance" account--this is a free mailbox in the access.net domain, which will also serve as your username to authenticate when your aDSL circuit becomes active.

Please enter your choices (in order of preference) for this email address:

*Choice 1: @access.net
*Choice 2: @access.net
*Choice 3: @access.net

NOTE TO CURRENT USERS: You may select the same username as your shell account, but it will be a separate mailbox, and you must authenticate your aDSL circuit with this username, NOT your shell username.

Add-ons

Unix shell account

Add a Unix shell account? ($5/month extra)
NOTE to current Panix users: You can use your current Panix shell account for this, and its price will drop to $5/month.

Enter your current shell login, if applicable:

Do you want Dial Backup? (starts at $5/month extra)

Would you like to pay in advance for the full year at a "one free month" discount?

Additional info (e.g. access, limitations, special instructions):

Where Did You First Hear about Panix ADSL?

I agree to purchase Panix Personal DSL at the above address for a minimum of one year's service. I have read and agree to pay all fees and costs of a standard Panix ADSL setup, including installation and hardware costs as of this date. I understand that my location must be a residence. I also understand that there is a $150 cancellation fee for termination during the contract period.

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webmaster@panix.com | Last modified: Thursday, 21-Dec-2006 14:19:17 EST

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