Domain Name Registration Fax Form

Please print out the form, fill it out, then fax

Step 1.  Check Domain Availability:  (click here to launch a new window for search)
Step 2.  Click Here to PRINT THIS FORM  
(or choose print in your browser's file menu)

Please fill this out COMPLETELY to avoid processing delays.

First Name: ______________________________ Last Name: _______________________________________
Company/Organization (if personal site, leave blank): ______________________________________________
Street Address: _________________________________________________ City: ______________________

State/Province: _____ Zip/Postal Code: __________  Country: ______________________________________

Phone Number: __________________________ Fax Number (not required): ___________________________
Email Address: ____________________________________
How did you hear about our service?:___________________________________________________________

Are you interested in Website Hosting, Website Design, Permanent Email, and/or Domain (URL) Forwarding?
[ ]Yes  [ ]No

Step 4.  Enter up to 5 domain names you would like to register.
Please be sure to include the domain extension (.com, .net, .org)

Important Notes:
There is a 63 character maximum including the 4 characters used to identify the top-level domain such as .COM, .NET, .ORG
May contain letters, digits, and a dash ("-").  Cannot begin or end with a dash.
Do NOT use any spaces.
Examples: (this is a 14 character domain name)
            (this is a 16 character domain name)

Domain 1: ___________________________________________________________________
Domain 2: ___________________________________________________________________
Domain 3: ___________________________________________________________________
Domain 4: ___________________________________________________________________
Domain 5: ___________________________________________________________________

Step 5.  Terms and Billing
Credit Card Type: [  ] American Express   [  ] Discover    [  ] MasterCard    [  ] Visa    [  ] Diner’s Club    [  ] JCB
Full name on card: ________________________________________________________
Card Number:____________________________ Exp. Month: _____ Exp. Year _______
Credit Card ID #____________ (an additional 3 to 7 digit number found on either the front or backside of the credit card)

I have scrolled through, read and accepted the entire customer service agreement (Sign Here):X _________________________

Thats it!  Well take care of the rest and contact you by E-mail as soon as we get confirmation of the registration(s).  Thank you for using!