Shared Hosting Order Form

	Shared Server Order Form (Basic)

	*1. Account Information Required Fields**
	Domain Name:	*(mysite.com) This is the domain you registered for your web site. If you do not have a domain name yet, please check here and we will contact you to assist you in obtaining one.
	Hosting Plan:	*
	Add Stats:	$5.00/month (Included on Linux Plan)
	Add Domain Pointer:	$5.00/month Domain name: If you have a second domain name and wish to point it to your primary domain
	Add Dialup Account:	$15.95/month (This is a 56K dialup nationwide access)
	Special Instructions:

	2. Customer Information
	First name:	*
	Last name:	*
	Company:
	Address1:	*
	Address2:
	City:	*
	State/Province:	*
	Zip/Postal code:	*
	Country:
	Phone:	* ext.
	E-mail:	* Your account information will be emailed to this address.
	How did you hear about us?:	*

	3. Billing Information
	Payment Method:	*
	Cardholder name:
	Card number:	No spaces between numbers
	Expiration date:
		Address on credit card same as above. Otherwise please provide the billing address below.

	Address1:
	Address2:
	City:
	State/Province:
	Zip/Postal code:
	Country:
	Referral ID:	You must fill this box with the correct ID of the person who referred you for him/her to receive proper credit.
	Promo code (if you have one)
	4. Online Signature
	AGREEMENT TO TERMS By typing your name in the "On-line Signature" below, and pressing the "Submit Order" button below, you hereby agree to the Terms and Conditions and hereby authorize all expenses associated with this account. Additionally your monthly charges are authorized to be billed, when due, to this account.
	On-line Signature:	* e.g. John C. Doe The name in this box must match the name provided in section 3.
		TERMS AND CONDITIONS