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Date:  Invoice#:   * required Forwarding Information  Input Below Information ONLY if ordering URL Forwarding Hosting Plan: Url Forward info: Email Forward info:  * Your Domain Name       whois lookup Changing registrar's NOT Required!    *   However; would you want us to handle your registration? Yes No Free Domain Name Registration with all (2) two year Hosting orders   * existing www. Our name servers   Do Not already have a Domain Name? Click here to Register.  * Registrant Information   *  Company/Organization:  (Individuals Enter Owner Name)  *  Street Address:  *  City or Town:  *  State: ---- select --- Outside North America --------------- Alberta Alabama Alaska American Samoa Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Fed St of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Manitoba Michigan Minnesota Mississippi Missouri Montana New Brunswick Nebraska Newfoundland Nevada New Hampshire New Jersey New Mexico Nova Scotia Northwest Territories New York North Carolina North Dakota N Mariana Islands Ohio Oklahoma Ontario Oregon Prince Edward Island Palau Pennsylvania Puerto Rico Quebec Rhode Island South Carolina South Dakota Saskatchewan Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon n/a Province: (if outside N.Amer.)  *  Zip Code:(or postal code)  *  Country: Contact Information  * First Name: * Last Name: * Phone: * Email Address: Hosting Plans & URL Forwarding Charge to My Credit Card: *   ---- select --- Web Lite "Entry" plan $3.25/month Bi-Annual billing - $78.00 Basic Web plan $9.99/month Annual billing - $120.00 Starter Web Plan $6.99/month Bi-Annual billing - $168.00 Advanced Web plan $14.99/month Annual billing - $180.00 --------------- URL Forwarding Web Package plan Annual billing - $25.00       Choose (2) two years; Get FREE Domain Name Registration? Yes No Credit Card Information * Pay With    Visa® MasterCard® Discover® * Name on card: exactly as appears on card. * Credit Card #: * Expiration: Month/Year --01 02 0304 05 0607 08 0910 11 12 -- 070809 10 1112131415 * Card Issuing Bank Name: CVV2 Security Information! You must include the 3 or 4 digit code (CVV2) from your credit card in order to complete this transaction. This is an added security measure to protect your data. Click here for more information. * CVV2 #: CC - Credit Card Billing Information This would be the billing address on record with the Credit Card issuer. * Street Address: * City:  *  State or Province: ---- select --- Outside North America --------------- Alberta Alabama Alaska American Samoa Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Fed St of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Manitoba Michigan Minnesota Mississippi Missouri Montana New Brunswick Nebraska Newfoundland Nevada New Hampshire New Jersey New Mexico Nova Scotia Northwest Territories New York North Carolina North Dakota N Mariana Islands Ohio Oklahoma Ontario Oregon Prince Edward Island Palau Pennsylvania Puerto Rico Quebec Rhode Island South Carolina South Dakota Saskatchewan Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Province: (if outside N.Amer.) * Zip or Postal Code: * Country: * I agree with Terms & Conditions: Yes No Verify input before submitting. If your Broswer is having trouble with this form PLEASE email us ... All CC Orders are confirmed First Before being set up

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