W e b   H o s t i n g   O r d e r   F o r m

 

Required Fields

1.  First and Last Name:

2.  Email Address:

3.  Telephone:

4.  Plan to pay using:
  Paypal
  Check/Money Order
(must clear before account is activated)
  Credit Card/Debit Card
  Other

5.  Email address used for Paypal:

6.  Username you wish to use for your hosting acct:
Must be less than 8 characters.

7.  Password you wish to use for your hosting acct:
Must be less than 8 characters.

8.  Existing domain, if you have one:
Please also answer question #12.
http://

9.  Domain you wish to register, if you don't have one:
www..

 

10.  Please choose your package:
Monthly:   Package 1   Package 2   Package 3   Package 4   Package 5   Package 6
6 Months:   Package 1   Package 2   Package 3   Package 4   Package 5   Package 6
Yearly:   Package 1   Package 2   Package 3   Package 4   Package 5   Package 6

 

11.  Which of the following describes you?
I have a domain already   I want to order a domain myself   I want you to order my domain

 

12.  Do you want to .....?
change your nameservers yourself?  
for me to change your nameservers for you?  If so, please answer #13
N/A

 

13.  If you want me to change your nameservers for you, please provide the following:


 

14.  Any other comments, anything I need to know or questions you have:

 

If the form submits correctly, you will be taken back to the home page.  If it doesn't, please resubmit!

 

 

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