Web hosting order form

Customer Information
Hosting Package:
Business Name:
Firstname:
Lastname:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Admin E-mail Address: this is the primary contact e-mail address for this account
Billing E-mail Address: if different from above, enter an e-mail address to sent billing info to
Alternate E-mail Address: please enter an alternate contact e-mail address to use incase your admin e-mail is not working
Telephone:
Fax:
Cell/Alternate Phone:
Your Domain Name: Enter the domain name you would like to use for this account. Do not include the "www." and be sure to include the extension.. example: mydomain.com.
Your Web Domain Name: In most cases this will be "www." plus your domain. However you can use an alternative subdomain if you wish. example: www.mydomain.com.
Choose a Password: no spaces, at least 6 characters please
Password Reminder Question: incase you forget your password and your e-mail address is no longer valid
Answer: to the password reminder question you have just chosen above