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Basic Contact Information

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Web Hosting Account Plan

(Linux) Base-Host
Charges Breakdown: $95.40/year TOTAL. Please enclose $95.40.
Charges Breakdown: $166.80/2 years TOTAL. Please enclose $166.80.
Charges Breakdown: $250.20/3 years TOTAL. Please enclose $250.20.
   
(Linux) Tera-Host
Charges Breakdown: $143.40/year TOTAL. Please enclose $143.40.
Charges Breakdown: $262.80/2 years TOTAL. Please enclose $262.80.
Charges Breakdown: $394.20/3 years TOTAL. Please enclose $394.20.

If you are ordering a DEDICATED SERVER or VIRTUAL PRIVATE SERVER we need to talk to you first. Please call us at (800) 725-9170 and we can explain the fast and easy process. You won't need this form.


Hosting Account Information

Domain Name:    www. .
   
This is a new domain. Please register it for me. (No charge)
I would like to use the above domain.


Signature and Date


By signing and submitting this form, you agree to adhere and follow the provisions and clauses found in the HostICan Terms of Service Contract and Acceptable Use Policy found at this URL: http://www.hostican.com/company/terms.php please make payment to HostICan.

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