WinstonNet > Bridging the Digital Divide

Application for Account Form

For a Printable version of this form please click here.

Name (First, Middle, Last):
Street Address:
Street Address 2:
City, State, Zip:	,
Telephone Number:	- ext.

By submitting this account request form, I acknowledge that I have read and understand all WinstonNet policies. I affirm that I will accept certain privileges and adhere to these regulations during my usage of a WinstonNet account and/or computer.

Please enter your initials to serve as your digital signature:
Current date:	,

IMPORTANT: When your account is created all necessary information regarding your login and pass word will be provided to the center supervisor at the WinstonNet computer lab location that you indicate below.

Please indicate which WinstonNet location you are at currently:
Recreation Centers:
Community Knowledge Centers:
Libraries:
Other Community Computer Centers:
Other (please explain):