This page should take you to our location in 3 seconds,
if it doesn't click on the link below:
New Location

PC Doctor Internet Contract for


1. Fill in the form, make sure to delete unused information, make sure to fill in completely, partial blank forms will not be processed.

2. Print out this form and fax it to us at

(757) 723-0603

3. Click on submit to send it to us, make sure you erase the credit card information, or it will be sent by email to us.

[FrontPage Save Results Component]

Personal Info


Birth Date:

SSN: (this will be used for security, to verify that you are you)





Zip Code:

Home Phone:

Work Phone:

Payment Type:  Today's Date:


Card info:

Name on Card:

Card Number:

Expiration Date:/


Check Info:

Check Number:

Routing Number:

Account Number:

Service Selected:



If bills are paid by check draft, debit card, or credit card; PC DOCTORS, LLC or its representatives will debit your account for the total amount due.


Requested Access Info

DIALUP USERNAME: (maximum characters is 10, lower case only)

DIALUP PASSWORD: (maximum characters is 10, lower case only)

E-MAIL USERNAME: (maximum characters is 10, lower case only)

E-MAIL PASSWORD: (maximum characters is 10, lower case only)


Your e-mail address will be (your email username)




  1. I certify that I am 18 years or older.

  2. I understand that PC DOCTORS, LLC will not be held responsible for any information originated, forwarded, or in any way transmitted via the internet that bears criminal intent. This includes the use of instant messaging, electronic mail, web page postings, club memberships, chat rooms or other internet activities.

  3. Payments must be made by the 1st day of your anniversary date. If payment is not received, I understand that my account will be considered past due and that my internet service will be discontinued until payment is received. If my internet service should be discontinued, I understand that I will be assessed a $10 re-connect fee. I understand that I am liable for any past due amounts on my account prior to the disconnect. I also understand that I will have to pay for court cost and attorney’s fees if this goes to court for collections.

  4. If there is intent to discontinue your account for internet service, notification must be received before the 1st day of your anniversary date. Otherwise, you will be billed for the entire next month. If I should request that my internet account be discontinued, I understand that my signature WILL BE REQUIRED prior to disconnecting. I further understand and agree that I am liable for all charges incurred on this account.


I have read and agree with all provisions set forth in this contract.






(Customer Signature)

Faxed copy has to be signed before internet access is turned on.


 By clicking on the submit button, you are requesting to have an internet account set up in your name, you agree to the terms and conditions above, and that you will be financially responsible for all bills that are generated by your use of our internet service.

PC Doctors, LLC, 1248 N. King St., Hampton, VA 23669 
Phone (757) 727-9263, Fax (757) 723-0603
Contact Roger Brehm email


Copyright 1995-2001 Roger Brehm, PC Doctor, PC Doctors, LLC

Hit Counter

Last updated: June 30, 2003