Registration Form

The North Carolina's Outer Banks Internet Initiative

Full Name

Title

Organization

Department

Street Address

(Area Code) Telephone

City

State

Zip Code

Service(s) Requested:

ÿ Small Business Sponsorship

ÿ Standard NCOB Sponsorship

ÿ NCOB SuperSite

ÿ NENC Partnership Site

ÿ Advanced Site

ÿ ARF

Existing Domain Name (If Available - Sponsors Only - For Example - http://www.outer-banks.com)

Indicate Material(s) Available For Inclusion In Your Corporate Site: (If Applicable)

ÿ Color or B/W Company Logo

ÿ Business Photograph(s)

ÿ Printed Company Description

ÿ Company Brochure or Ad

ÿ Other Printed Documentation

E-Mail Address (If Available - Sponsors Only)

_____________________________________

Target E-Mail Address for Linkage(s)

(Sponsors Only)

Billing Information (if different from above) Ruffin Associates will send invoices directly to your Accounts Payable Section. Accounts more than 30 days past due will result in the termination of your account. Late charges and re-installation fees will be required before reinstatement of your account.

Full Name

Title

Organization

Department

Street Address

(Area Code) Telephone

City

State

Zip Code

Authorization

I hereby authorize Ruffin Associates to provide the products and services indicated herein and as described in the attached Subscriber Agreement. Ruffin Associates will use its best efforts to provide the highest practical level and quality of service; however customer agrees that Ruffin Associates makes no warranties, express or implied, in connection with the service provided hereunder. Customer hereby waives all claims against Ruffin Associates whether in contract, tort, or strict liability, for damages, losses, or injuries in connection with or arising out of this Registration Agreement.

_______ __________________________

Signature and Date

___________________________________________

Name (PRINT or TYPE)

___ _______ ______________

Title