Hosting Package |
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(Do not include or prefix with "www.") |
Username |
(Maximum of 8 alphanumeric characters) |
Password |
(10-18 alphanumeric and special characters) |
Organization Name |
(optional) |
Name (First) |
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Name (Middle Initial) |
(optional) |
Name (Last) |
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Postal Address Line 1 |
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Postal Address Line 2 |
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City / Town |
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State / Province |
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ZIP / Postal Code |
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Country |
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E-mail Address |
(If you only have one address ...) |
Alternate E-mail |
(...then enter the same for both.) |
PayPal E-mail |
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Tel. Country Code |
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Area Code & Tel. # |
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Fax Country Code |
(optional) |
Area Code & Fax # |
(optional) |
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Instant Messenger Contact Information |
This information is optional, but will help us to provide more in-depth and interactive technical support.
It may also be used to assist in verifying your account ownership if you contact Support over IM. |
AIM (optional) |
(AOL Instant Messenger) |
Google Talk (optional) |
(Google Talk, Instant Messenger) |
ICQ (optional) |
(ICQ, Instant Messenger) |
Jabber (optional) |
(Jabber, Instant Messenger) |
MySpaceIM (optional) |
(MySpaceIM, Instant Messenger) |
Skype (optional) |
(Skype, Instant Messenger) |
Twitter (optional) |
(Twitter, Instant Messenger) |
WLM/MSN (optional) |
(Windows Live (MSN) Messenger) |
Xfire (optional) |
(Xfire, Instant Messenger) |
Yahoo (optional) |
(Yahoo! Messenger) |
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Notes |
You may wish to include additional notes to help specify preferred customizations or other requests.
(i.e. someone referred you, or you need account data transferred from a previous service provider or host) |
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Anti-Fraud Data Logging |
Your IP Address |
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Your Host Name |
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Your User-Agent |
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HTTP Referrer |
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Request URI |
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Order Time Stamp |
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