ORDER FORM



Name:           
E-Mail:         
Street Address: 
City:		
State/Province: 
Zip Code:	
Country:        
Telephone:		

Please list your 3 domain name choices in order of preference:
1st Choice Domain: 
2nd Choice Domain: 
3rd Choice Domain: 
What is your company name?: 


Please choose your website package:


Do you need more pages than offered in the package you chose? You can order additional pages.
If the package you chose includes 5 or more pages, additional pages are $50. each.
If the package you chose includes less than 5 pages, additional pages are $75. each.

Please enter the number of additional pages you require:

If applicable, what is your existing web site address?:


Your Credit card will be charged a Deposit of $350. now and the balance at completion of the web site.
(Packages valued at less than $350. will be charged in full.)

Please note that all prices on this website are in US Funds. We accept Visa and Mastercard.

Paymeant Type:       
 

Secure payments with Credit Card:
Card Number:               
Expiration Date: (enter month then year like this: 05/04)


Regardless of your payment method, you must print out and fax to us the Paymet Authorization Form.
Orders will not be processed without payment and this signed document. 
You may fax the form to us at (514)906-0626.