NissR Hosting Order Form

You want to order:

The hosting package: Town-250MB.
Payment: Annually - by Check.
Price: $US 13.95.

We need the following information to be able to process your order:

Domain NameYour Domain Name

Do you want us to register your Domain?
No, Do Not Register
Yes Register it for 1 year
Yes Register it for 2 years
Yes Register it for 10 years
User name:Choose a user name for this domain:
Password:Choose a password for this domain:
Re-Password:Confirm your password:
Name: First Name and Last Name of the domain Owner or Administrator:
Company (optional):Company Name:
Street Address:
City:
State or Province:
(If applicable)
Zip (Postal Code):
Country:
Phone:
Fax (optional):
Email: Email of the domain Owner or Administrator:
Hosting Package: How many years do you want to pay in advance?
One Year
Two Years
Ten Years
Front Page
Extensions		Do you want to enable Front Page Extensions for this account?
Yes
No
Comments or
special instructions:

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