PRE-PAID CONTRACT FOR WEBHOSTING

Important:

This form is only for new customer use. Existing customers should use the existing customer form.

Instructions:

Please fill this form out on your computer, then print. If you decide to complete the form manually, please write
carefully - if we cannot read your contract, we cannot process it!




(customer name)

phpwebhosting.com Payment Processing
P.O. Box 4476
Indianapolis, IN 46082-4476
U.S.A.

Choose a prepayment plan:

_____ Enclosed is $238.80 U.S. Dollars payment for 24 months of webhosting.
_____ Enclosed is $119.40 U.S. Dollars payment for 12 months of webhosting.
_____ Enclosed is $59.70 U.S. Dollars payment for 6 months of webhosting.

I understand that my payment will take effect upon receipt.

Please create my account as follows:

Desired Username (8 characters max.):

Password (12 characters max.):

Domain Name (optional):

Account Holder Name :

Email Address :

(Note: Please do not use an email address @yourdomain. If possible, enter an address that is not associated with your domain. We need an "outside" address to contact you in case there are ever problems with your domain.)

Address Line 1 :

Address Line 2 :

Address Line 3 :

City :

State/Province :

Zip Code/Postal Code :

Country :

I understand that this contract cannot be cancelled and that refunds are only
made during the first 30 days of hosting.

I am 13 years of age or older.

Signed:

___________________________________________
(printed name)

___________________________________________
(signature)

___________________
(Date)


Print this form out and send the completed form along with payment in U.S. Dollars to:

phpwebhosting.com Payment Processing
P.O. Box 4476
Indianapolis, IN 46082-4476
U.S.A.

Payment can be made by Check or Money Order. No cash please.

Please allow 7-14 days for check payments to be processed.

Note: If you would like immediate access to your account, please send us a message from the contact us link on our main page and we will set-up your account while we wait on your payment. Please include all of the information above (name, address, username, password, etc.) with your request.


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