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Email Hosting Order Form
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Email Hosting Order Form
1
Basic Shared Hosting Information
2
Contact & Billing Information
Email Hosting
Domain Name
*
Primary Domain Name i.e. mywebsite.com. Only one per hosting account. Do not include “http://www”.
Domain Name Registration
New Registration (Buying a New Domain)
Transfer (Transfer your existing Domain)
Additional Email Accounts
Price:
$1.00
Quantity:
Email Accounts
List up to 25 email accounts.
Notes/Comments
List any additional email accounts you need.
Name
*
First
Last
Business Name
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
*
Billing Method
Invoice
Mastercard
Visa
American Express
Note: Hosting charges are billed in advance and then every quarter.
Credit Card Number
Last 4 Digits
Note: If paying with a credit card, please call within 24 hours of submitting your order to provide your full credit card number.
CC Exp. Date
MM/YYYY
Name on Credit Card
*
First
Last
Agreements
*
I agree to SiteVision, Inc.’s
Terms and Conditions
I agree to SiteVision, Inc.’s
Acceptable Use Policy
I agree to SiteVision, Inc.’s
Service Level Agreement (SLA)
Total
$0.00
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