Infopage Services Host Non-Secure Order Form
Please contact us immediately if you have problems using this form.

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Billing info:

First Name:

Last Name:

Email Address:

Business/organization Name:

Please note that Internic will bill you directly for Domain name registration.
The current registration rate is $50.00/year first two years payable in advance.
Their Normal terms are 30 days from activation.

Organization description or special notes

Address Information:

Line 1:Line 2:


Zip/Postal Code:Country:

Phone: Fax:


SOHO  Business 1 Business 2

Corporate 1 Corporate 2 Corporate 3

Reseller  Adult 1  Adult 2

Adult 3   Adult 4  Adult 5

Options requested:

Microsoft Frontpage (most cgi scripts supported)

Real Video/Audio $25.00/mo Real Audio $12.00/mo

Java Chat $12.00


Domain Information:

If you are a reseller, your Domain name:

New Domain

Modified/Transferred Domain

Domain Name (if existing)

Requested Domain Name

Second Choice

Requested Domain Password

The admin. contact is for internic registration, use if you want internic to register and bill domain to an entity other than our billing contact.. 

Administrative contact (for new domain only) Name:

Administrative contact address   City:

State: Phone:

Payment Method:

Credit Card

Check online/fax

Snail Mail (credit card/check or money order US funds)

NOTE:  All check/money order payments require a first and last
month's deposit.  Please submit three month's charges, plus setup
fees.  Don't forget to add amounts for options.   Contact us if further
arrangements are necessary.
Credit card Info:
Name on Card:
Card Number:


Card Type: Visa MasterCard American Express Discover

Check Information:

Take care in filling out all the information correctly.

Name (as appears on check): 

CHECK PAYMENT INFO: (As it appears on your check!)
Note: If you're confused as to what is what on your check, asks your banker will be happy to help.

Address:	Line 2:


Zip/Postal Code:Country:

Check #:     
 NOTE: Get out your check book and use the next available number
  Be sure to make an entry for this check in your Check Register

             Bank Name: 
          Bank Address: 
             Bank City: 
            Bank State: 
         Bank Zip Code: 
          Phone Number: 
  Bank Routing# (ACH#): 
    NOTE: The routing # digit# at the bottom of your check on the 
          MICR Line. Most likely the left-most series of numbers

Branch Fraction:  TOP#:   BOTTOM#: 
  [ NOTE: This is the Fraction at top-right of check near the check# ]

      Your Checking Account#: 

      If your account has pre-digits enter your account number as NNN|XXXXXX where NNN are 
      the predigits ( the number 725 before the customer number in the above example)
      and XXXXXX is your account number. Always separate the two with |

            Bank Draft Total: 

 Check this box to Authorize payment for the total amount listed above by bank draft.
 Check to authorize check to be made out to "Infopage Services" 
These 2 boxes must be checked in order to process your account.  

Infopage Services
5261 Highland #395
Baton Rouge, La. 70808