November 20, 2008 HOME SERVICES SUPPORT COMPANY CLIENTS CONTACT

Web Hosting Order Form

Account Information

Organization Information
Are you applying for a new domain name or moving your owned domain from another provider?
New Domain Moving from another Provider		 Company Name:
Domain name:
 		Street Address:
Your desired username:
 		City:

Password: 

State:

Postal Code:

Verify password: 

 Country:

Administrative Contact

 Billing Contact
Billing contact is the same as Administrative contact

Contact Name:
 		Billing Name:
Street Address:
 Street Address:
City:
 		City:

State:

Postal Code:

State:

Postal Code:
Country:  Country: 
Phone Number:  Phone Number: 
Fax Number:  Fax Number: 
E-mail:
 E-mail:
Hosting Package
Select desired Hosting Package:
Starter ($8.00/month)    Basic($10.00/month)     Bronze($19.95) Silver ($26.95/month)    Gold ($29.95/month)

By submitting this application, you agree to obey the Hosting Contract
I have read and agree to the hosting terms

 

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