Application Form

NetRom New User Setup Form

You MUST fill out this form to use NetRom Internet Services. Incomplete or inaccurate information will not be accepted. If you have any difficulty please call (973) 208-1339. You MUST press the "Send Setup Form to NetRom" (at the bottom of this form) or your application will not be submitted. After pressing the submit button you will get a screen of information advising what to do next. If not, please call the above number to have your account setup.

  1. NAME - must be your legal name.
  2. LOGIN - lower case, no spaces, may be a nickname or handle.
  3. PHONE NUMBER - must be a number where you can be reached by voice. (Telnet only accounts MUST put your current email address!)
  4. ADDRESS - where billing/newsletters are to be sent.

Name: Phone #: Day Eve
Billing Address1:
Billing Address2:
City: State: Zip:

Login Name (max 8 char.) :
Password (min 6, max 20 char. CASE Sensitive!):

Account type (select):

How did you find out about NetRom:

Refered By:

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