ChathouseTM Personal Chat Site Order Form

The Chathouse™ Personal Chat Site Order Form Simply print and complete this webpage form, sign where required, and mail with your check or money order or mail or fax with credit card charge authorization to: Channel 1 Internet, Attn: Personal Chat Sites
1030 Massachusetts Avenue; Cambridge, MA 02138
FAX: 617-354-3100

Name (in Real Life):       ________________________________________________
Phone Number (optional):   ________________________________________________
E-Mail Address required):  ________________________________________________
Please contact me upon receipt of this Order Form:
                           ______ by Phone  and/or   ______ by E-Mail

I am ordering the following Chathouse™ Personal Chat Site services:
Set Up Fees:
  _____ Set Up/Install (set permissions/configurations, $100)     $________
  _____ Custom Design Fees (if any, attach quote from Channel 1®) $________
Monthly Fees:
  _____  6 slots (minimum room size, $100/mo)                     $________
  _____ 12 slots ($150/mo)                                        $________
  _____ 18 slots ($200/mo)                                        $________
  _____ Public Listing in ch@tmosphere (add $50/mo, if elected)   $________
  _____ Custom Services (if any, attach quote from Channel 1®)    $________

Total Due (Set Up PLUS First Monthly Fees) for This Order:        $________

  _____ Enclosed find my Check or Money Order in the amount of  $__________
OR,
  _____ Please charge $__________ to my   ___Visa ___AmEx ___MC ___Discover
        Credit Card #: _______________________________  Exp.Date __________
        Name as it appears on card:  ______________________________________
        Authorizing Signature:  ___________________________________________

By signing here below, I declare that I own the copyrights for, and/or have 
been granted appropriate copyright permissions for, all of the artwork, text 
and images to be presented in my Personal Chat Site.  Further, I assume all 
copyright infringements risks and responsibilities for any use of the 
electronic web images contained therein.  I also declare that this Personal 
Chat Site will only be used for personal and recreational use and will not 
be used to promote, sell, provide, or facilitate the sale of any commercial 
goods or services.  As this Personal Chat Site will be hosted on the Channel 
1® Chathouse™ it's general rules and terms of use are governed by the same 
Rules and Terms of Use as are publicly posted on the Chathouse™ website at 
http://www.chathouse.com/rules.html and on the Channel 1® website at 
http://www.channel1.com/support/sysusepolicy.html

_________________________________________________    ______________________
       (signature, required)                                 (date)

Thank You for your interest in our Personal Chat Sites. We will contact you as soon as your completed Personal Chat Site Order Form is received.

Channel 1 reserves the right to refuse any requested chat services, for any reason, at any time.

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