Services Host Non-Secure Order Form
Please contact us immediately if you have
problems using this form.
Please note that Internic
will bill you directly for Domain name
The current registration rate is $50.00/year
first two years payable in advance.
Their Normal terms are 30 days from
Organization description or special notes
Line 1:Line 2:
SOHO Business 1 Business 2
Corporate 2 Corporate 3
1 Adult 2
Adult 3 Adult
4 Adult 5
Microsoft Frontpage (most cgi scripts
$25.00/mo Real Audio $12.00/mo
Java Chat $12.00
If you are a reseller, your Domain name:
Domain Name (if existing)
Requested Domain Name
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..
contact (for new domain only)
Administrative contact address
Mail (credit card/check or money order US
Card Type: Visa MasterCard American
Take care in filling out all the
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:
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 Zip Code:
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.