Website Hosting Order Form

First Name:

Last Name:

Email:

Business Name:

Please note that Internic will bill you directly for Domain name registration. The current registration rate is $50.00/year first two years payable in advance (this does not apply to domains that are just being transfered).
Their Normal terms are 30 days from activation.

Description of your organization and any special notes

Your Address:

City:

State:

Zip:

Country:

Phone:

Choose Account Type:
Business Domain $29.95 / month
Corporate Business $59.95 / month

Options:
Microsoft Front Page Setup
Real Audio $8.00 / month
Real Video & Audio $12.00 / month
Java Chat Room $8.00 / month
Volano Chat Room $12.00 / month

Domain Name Choice:
Register New Domain
Modify Existing Domain (transfer existing domain to our server)

Choice of domain: (or domain to transfer)
All lowercase - no caps

Second choice of domain: (if above is unavailable)

Desired Password:
Use up to 8 characters

Where did you find us?

How do you wish to pay?

Credit Card (Mastercard, Visa, Discover, American Express)

  • You will be charged Setup, plus 1st month or remainder of this month
  • Billing cycle is adjusted to the 1st of every month and your account will be automatically debited
  • Your account will be setup with access within 12 hours

    Check or Money

  • Accounts must be paid Quarterly
  • Please Mail 3 months plus setup charge
  • Your account will be setup with access within 12 hours after payment has been received

    Credit Card Information

    Card Type:
    Visa
    Master Card
    Discover Card
    American Express

    Card number:

    Expiration:

    Name on Card:

    Cardholder Address:

    Cardholder Phone:

    Bank Phone Number:     (Found on credit card)


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    1 (800) 369-4966