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Contact Information

* Name (first, last):	,
* Email Address:
* Address:
* City:
* State/Providence:
* Zip Code:
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Domain Name & Hosting Account Information

* Domain Name: http://www.
* Choose Your Account Username:
* Choose Your Account Password:

Choose Your Hosting Plan

Choose Your Plan:

2 Payment Options

	Option 1. I will pay using a credit card (Details on next page)
	Option 2. I will sends funds via Paypal.com (Details on next page)

Please Check Your Required Hosting Features (no additional charge)

	Server Side Includes (SSI)
	FrontPage Extensions
	MySQL/myPHP Admin

Acceptable Use Policy (AUP) & Terms of Service (TOS)

I have read and agree with the terms presented in the AUP & TOS.

You will receive a welcome email containing the URL to your Online Control Panel, Account Information, CGI Script Resources, and Tech Support Contact Information.