ACCOUNT ORDER FORM
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Web Hosting $300.00 (Pre-paid 1 Yr in Advance)
.................................... $ .
Web Page Hosting $119.40 (Pre-paid 1 Yr in Advance) ........................... $
.
Additional fees
.............................................................................................$
TOTAL $ .
All currencies are in US Dollars
Domain Name registration fees ($70.00 for the first two years) will be billed directly from InterNIC
DOMAIN NAME:
Domain Name Hosting: www.
Web Page Hosting: www.mannygeller.com/
CONTACT INFO:
Company Name _________________________________________
First Name
_________________________________________
Last Name
_________________________________________
Address
_________________________________________
City
_______________________________ State _____
Zip/Postal Code _______________
Country
_________________________ Country Code ____
Phone
(____) ____-______
Fax
(____) ____-______
*Email Address [________________________________________]
*REQUIRED - Account Information will be mailed to this address
**Please choose your FTP account password [___________]
-
Must be at least 2 characters and no more than 8
- Passwords
are case-sensitive (PassWOrd is not the same as password)
**REQUIRED - For Domain Hosting Service
Signature of person filling out form: _________________________________________ ( Indicates the acceptance of Term & Conditions )
Make Check or Money Order payable to Manny Geller
WebHosting
Prices subjects to change without notice.
52305
---------------------------------- ( Cut This and Use It As A Label ) -------------------------------------
MannyGeller. COM, INC.
21401 N.E. 23rd Ave
Miami, FL 33180