*First Name: *Last Name:

Title: Company:

*Address: Address Cont.:

*City: *State: *Zip:

*Phone: Fax:

*Email Address:

Yes No

Hosting Plans:

$24.95/Mo. - BASIC PLAN: 500 MB Diskspace, Up To 10 E-mail Accounts, Daily Backups

$49.95/Mo. - ENHANCED PLAN: 2 GB Diskspace, Up To 25 E-mail Accounts, Cold Fusion & Daily Backups

$69.95/Mo. - PREMIUM PLAN: 5 GB Diskspace, Up To 100 E-mail Accounts, ColdFusion, Shopping Cart & Daily Backups

$99.95/Mo. - CORPORATE PLAN: Virtual Dedicated Server, 20 GB Diskspace, Unlimited E-mail, ColdFusion, Shopping Cart & Daily Backups

Additional Options: (check all that apply)

$8.00/Mo. - TRAFFIC STATISTICS - Up to the minute statistical information about the traffic your website is getting

$10.00/Mo. - SEARCH ENGINE OPTIMIZER - Rate Your Website Higher On Google, MSN & Yahoo!

$10.00/Mo. - SSL SECURE CERTIFICATE - Keep your customers private data and credit card information secure

$75.00/Hr. - WEBSITE MENTORING SERVICE AND MAINTENANCE - Learn anything you want about your website, or have something updated

Domain Name:

Do you currently have a domain name (ex. www.yourdomain.com)? Yes No

If yes, where is it registered?

Do you have the login information to manage your domain name? Yes No

If yes: Username: Password:

If you do not have a domain name do you have some desired names? Since many domain names are unavailable, you will need to list multiple entries. What would you like to call your web site (1 being the most important)?

Email information

Primary email address requested example: info@yourdomain.com

Requested password You can reset this

Would you like this forwarded to an existing email account? Yes No

If so, what is that email address

Card Type: Visa Mastercard Discover Amex

Card #: Security Code:

Expiration Date: