Website Hosting Sign-up

NOTE: We never sell, transfer or in anyway give out and/or divulge our clients', or perspective clients', information.

Your Company Name    
Your Name    
Your Title   (owner, CEO, President, Etc.)
Your Email Address: 

Mailing Address:

          Phone:            Fax:   

Comments/Questions:
  

I currently do not have a Domain Name Registered and I want to take advantage
of your 'No Additional Charge' service to register a Domain Name.

My first choice is
Second choice is  
Third choice is    

Sample Website Layout
" "

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I confirm that I have selected the
following Hosting Plan :
Custom Plan (X) ( ) $ per year.

There is a 20% setup fee $ .

There are no Additional Hosting or Registration fees.

Please list any special offer or discount
that you qualify to receive:

You may pay just the setup fee with this sign-up form and an invoice will be sent to you for the balance.

Total Amount Paid $ with this form.

Your Satisfaction Guaranteed
If within the first 30 days you are not completely
satisfied with our service you will get
a 100% refund (less the setup fee)...
No Questions Asked.

Credit Card Information

Name of Authorized Signer

"EXACTLY AS SHOWN ON THE CARD"

Credit Card Type: (X) MC   VISA

Credit Card Number
Expiration Date of Credit Card (00/00)
3 or 4 digit security code
( What is this )

If your credit card statement is sent to a different address than your mailing address above.

Statement Mailing Address for the Card  
City, State, Zip: 

I authorize Whited Services to debit my card the amount shown above.

I have read and agree to the
TERMS OF SERVICE. (X) ( )

 

_______________________________________
Sign Here                               Date

Using your mouse; RIGHT click on this form.
Select 'PRINT' and then set the number
of copies (Minimum of two).

Retain a copy of this Sign-up Form for your records!
SIGN and mail one copy to Whited Services.