URL Order -

By completing and submitting the form below you are authorizing us to represent you in obtaining or managing an account and or its information that is used to support a URL and/or DNS information. Any and all information will be held in the strictest confidence. All actions will be made in the best interest of the Registrant. You will be notified of all resulting information needed to manage the account unless we are directed otherwise. In the event that we are to pursue continuing maintenance of your URL, we may need to list yourselves as part of your registration.

Date Submitted:
 2006

Source:
CoastlineCreative.com   WindFire
Other:

By:

URL Information:
A yearly fee of $8.95 per URL is charged by our registrar. Some .names are more expensive and will billed as such.

Desired URL: (or current if transferring)
. (.com)

2nd Choice:  
. (.com)

This is a first time request.

Transfer my existing URL to your registrar for $7.95 which will extend the expiration date one year plus the time left on the existing account. Longer terms are available. Subsequent renewals are $8.95 per year.

Current Registrar:


Registration Account Information:
 All spaces must be filled in!
Registrant: (Legal Owner of the URL)

,

   

Administrative Contact:
(Contact person for approving changes to the account)

,

   

Technical Contact: (Usually the builder of the site)

,

   

Billing Contact: (The person who pays the bill)

,

   

Registration Payment Information:

Contact me to make arrangements.
Bill me.

Use this Credit Card:

Expiration:


(AMX - the 4 small numbers above the last 4 numbers on the front of the card.)
(Visa/MC - the computer written numbers on the signature strip on the back of the card.)

Billing address if different than above:

,

   

Hosting Information:

Contact me to make arrangements.
I will apply here on your site.

Already have a host. Will need to inform them of the DNS information at:


eMail Setup: (if we are hosting your site)

 
eMail Address:      
 Password:
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Special or Additional Instructions: