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Today's Date:

18 Years Old/Older

Account No:

First Name: Middle Initial:

Enter Domain to Host
Last Name:
Company/Org: Username
Address Street 1:
Address Street 2: Password
City/State/Zip:
Work Phone:  
Home Phone:

 
List Any Desired Add-On POP3/Alias e-Mail w/Passwords
Set-Up By:

Formula = (Days to Prorate) x (Prorate Calc)
Order Desired
Services

How Many Days to Prorate:

Initial Invoice

Monthly Hosting

 (+) Add-On POP3 e-Mail @ $3mo   (Prorate = .0983)

 (+) Add-On Alias e-Mail @ $1mo   (Prorate = .0328)

Quarterly Hosting

 (+) Add-On POP3 e-Mail @ $9qtr  (Prorate = .0983)

 (+) Add-On Alias e-Mail @ $3qtr  (Prorate = .0328)

Yearly Hosting

 (+) Add-On POP3 e-Mail @ $36yr  (Prorate = .0983)

(+) Add-On Alias e-Mail @ $12yr (Prorate = .0328)
Static IP Address

Use MS FrontPage

Add FrontPage Support N/C   Set-Up Fee @ $25
Initial Payment

Amount Due
Amount Paid