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Account Options Include:  Windows NT · UNIX · Cold Fusion · Ecommerce

Web Site Hosting

To begin hosting service for your web site, please fill out this secured form completely and press the submit button. Once your order is submitted we will email you a confirmation that your application was received. IMPORTANT: If you do not receive a confirmation by the end of the next business day, your order was not received!

Company Name:
Zip/Postal Code:
Day Phone:
Night Phone:
First Name:
Last Name:
Organization Email:
Your Email Address:
Hosting Plan:

Credit Card:
Card Number:

Hostcentric Authorized Dealer :  
Technical Info
Domain Name:

Is your Domain name Registered?

Preferred Site Operating System:
Are you using Microsoft FrontPage to author web pages?
User ID: (3 Character Min. - No Special Characters i.e., @#$%)
(Your UserID is the basis for your mailbox ids. UserID changes are $30.)
Password: (10 Character Min. - No Special Characters i.e., @#$%)
   (You can change your masterpassword later, if you wish, without charge.)
List any comments or special instructions below:

  In case of trouble with this form, send email to webmaster.

    Updated: 10/24/04