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Sign Up for Dial-up Service Online!

Please fill out this form to request a dial-up Internet account.
(Find out more about High-Speed Internet options in your area.)

A Mid-Rivers Customer Services Representative will contact you after you submit this form to confirm your order and to complete the activation of your new Mid-Rivers dial-up Internet account.

Please provide us with the following information regarding your plan:

Username (3-10 characters, all lower case):  

You will also need a password. A Customer Service Representative will contact you personally for this information. 

Optional- Second Username (3-10 characters, lower case): 

(You may provide a second username if you want an additional e-mail address for FREE!)


Choose one of the following monthly plans:


Start Date of Service: -- mm/dd/yy


Please provide us with your contact information:

First Name:

Last Name:

Company / Organization:

Street Address:

Address (continued):

City:

State:

Zip Code:

Home Phone:

Work Phone:

Current E-Mail Address:


To verify your submission please type in the text you see above:


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