UNIX Hosting Plans

Please fill out this secured form completely and press the submit button.
Once your order is submitted we will email you with confirmation of your order.

Site Details
Domain Name:
Is this domain already registered?

if no,
would you like us to register this domain for how many years?

Server Details Do you require a database:

Which Hosting Plan:
Are you using Microsoft FrontPage to Publish your pages?
If yes, what version of Microsoft Frontpage? 2000/98 2002

UserID and Password
Please Note:
Your UserID is the basis for your mailbox ids and access to Customer Support.
Any UserID changes involve a $30 charge

User ID: (3 Character Min. - No Special Characters: @#$% or numbers )
Password: (8 Character Min. - No Special Characters: @#$%)
Confirm Password: (re-type your password in case of a typo)

Payment Information
This is a secure form, your card details will only be forwarded directly to Hostcentric

Credit Card:
Number:	Exp: Your statement will show a charge from "Hostcentric"

Contact Details

First Name:	Last Name:

Company Name:
Address:
City:
State:
Postal/Zip Code:
Country:
Day Phone:
Night Phone:
Fax:
Contact Email:

Other Information

Special instructions:

Web Design

Software

Company

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