Genesee Free-Net Individual Account Registration Form

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(All fields marked with an asterisk (*) are required)
 
Current e-mail address (if you have one):
 
 
Your name:

* First Name:   MI   *Last Name:
 
 
Your home address:
 
* Address:
 

   Address:
 

       * City: * State: * Zip: -
 

Your phone:

     * Day phone: --
 
      Night phone: --
 
      Cell Phone:   --
 
 
In the event you forget your password, we need the following information for security reasons: 

     * your birth date:

     * your mother's maiden name:
 
I would like an individual account. Cost = $60 annual fee
 
I would like an individual account. Cost = $35 six month fee
 
If you are applying for an account and have an address outside of Genesee County, please verify that you have a local call-in number listed on our webpage. Please note that help calls to the office will be long distance if you are located outside of Genesee County:
 
Operating system:

PC or Mac:


I've read the Genesee Free-Net Acceptable Use Policy and agree to its terms.
 
*SIGNATURE___________________________________   DATE______________
 
Parent/guardian signature is required for users under the age of 18:
 
SIGNATURE___________________________________   DATE______________ 
 
PRINT this completed form and sign for mailing with your check. If you do not have a printer available, please call or write our office to request a form be mailed to you.
 
810-720-2880