E-Market Media - Dedicated Server Order Form

*Name:
*E-Mail:
Company:
*Street Address:
*City, State, Zip:	, , +4 (if known)
*Phone:	( )
*Domain Name:	www. (e.g. yourdomain.com) Your Password Will Be E-Mailed To You If you do not have a domain name yet, we suggest you click here first in order to check availability and register your .com, .net, .org, .biz, .info, or .ws domain.
*Services Requested:
Comments, Questions, or Additional Requested Add-ons:
*Payment Type:	MasterCard Visa Amex
*Credit Card number:	exp date:
*Billing Cycle:	Quarterly Biannually Annually
Setup Charge:	All Dedicated Server Packages Include A Setup Charge, depending on your chosen Package, which will be included in your Final Total. We will email you, the customer, with the total amount due after calculating all additions, and will not charge your credit card until the final total has been confirmed by you.
Dedicated Server Plans are for a minimum term of twelve (12) months. The first and last month's rent will be included and paid at sign-up. All Dedicated Server Plans may be canceled with 30-days notice after your 12-month term expiration. By submitting this completed form I have read and agree to all the provisions stated in E-Market Media's "Terms Of Conditions And Acceptable Use Policy" and also that all of the above information is true and correct to the best of my knowledge. HOSTING POLICIES \| PRIVACY STATEMENT ©2001/2004 E-Market Media, All Rights Reserved

*Name:

*E-Mail:

Company:

*Street Address:

*City, State, Zip:

, , +4 (if known)

*Phone:

( )

*Domain Name:

www. (e.g. yourdomain.com) Your Password Will Be E-Mailed To You
If you do not have a domain name yet, we suggest you click here first in order to check availability and register your .com, .net, .org, .biz, .info, or .ws domain.

*Services Requested:

Comments,
Questions,
or Additional Requested Add-ons:

*Payment Type:

MasterCard Visa Amex

*Credit Card number:

exp date:

*Billing Cycle:

Quarterly Biannually Annually

Setup Charge:

All Dedicated Server Packages Include A Setup Charge, depending on your chosen Package, which will be included in your Final Total. We will email you, the customer, with the total amount due after calculating all additions, and will not charge your credit card until the final total has been confirmed by you.

Dedicated Server Plans are for a minimum term of twelve (12) months.
The first and last month's rent will be included and paid at sign-up.
All Dedicated Server Plans may be canceled with 30-days notice after your 12-month term expiration.

By submitting this completed form I have read and agree to all the provisions stated in
E-Market Media's "Terms Of Conditions And Acceptable Use Policy" and also that
all of the above information is true and correct to the best of my knowledge.

HOSTING POLICIES | PRIVACY STATEMENT