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Web Hosting Services
Order Form
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| Company Name |
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| Point of Contact |
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| Street Address* |
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| City* |
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| State/Province* |
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| ZIP/Postal Code* |
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| Country* |
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| E-mail (not associated with this domain name) |
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| FAX* |
We will send you the site setup to this FAX.
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| Phone* |
(we will call you
if we have any questions).
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Domain Name
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Package
Please pick one |
Standard Packages
Also set me up as a new PWDA |
| Special Features |
None PHP
MySQL Database
Simple Content/Catalog No Catalog
Content Only
see Custom Features below for added information you
need to supply.
Note: Selecting Catalog implies E-Business
unless you specify No Credit Card Processing
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| Name on Credit Card* |
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| Credit Card Number* |
last 3 digit on the back
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| Credit Card Expiration Date* |
03 2004
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| Credit Card Type* |
Master Card
Visa |
| Custom Features |
Include any domains which will
display the same content (i.e., aliases). Initially 3
emailboxes will be created, but you can add additional ones as needed.
If you are using a canned PHP package the name of the
database and username will be the same as that of the domain
unless you indicate otherwise.
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Service
Agreement
* Existing Clients who are current may leave these fields blank.
Activation should occur
within 1 business day. |