CareerAge - Internet Café Membership Signup form
Contact Information
Internet Café*
Contact Person Name*
Address
City
State
Country
Pin/Zip Code
Phone Number(s)
E-mail*
Facilities Information
Facilities* Beverages     Tea   Coffee   Cold Drinks
Snacks
Hardware Facilities* Printer     Color Inkjet     Laser Printer    
Scanner    
Any other facilities
Internet Access Rates
Membership Rate*
Hourly Rate*
Rates for half hour*
Other rate information*
Login Information
Login User Id*
Example:A good choice is a combination of first and last name
*  Mandotory fields
Important Note: As a small return gesture for providing you a presence on our site, CareerAge would like to be seen in your café. We would send you small posters to be displayed in your Internet café, along with some distributable material.