E-Market Media Hosting Order Form

*Name:
*E-Mail:
Company:
*Street Address:
*City, State, Zip:	, , +4
*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, .us, .info, or .ws domain. (If you want to take advantage of our Monthly Special's FREE Domain Registration DO NOT register here first, just include your domain above and click the appropriate button in the "Monthly Special" field below.)
*Services Requested:
UNIX HOSTING ONLY Please include the following add-ons (additional charges apply if not included with chosen hosting package)	Real-time audio/video Java chat room Volano chat room Miva Merchant Graphical referrer logs mySQL server database The below applies only to UNIX Basic Plus Plan Front Page extensions FTP access Secure Server access
Windows 2003 Hosting Only Please include the following add-ons (additional charges apply if not included with chosen hosting package)	Real-time audio/video Volano chat room The below applies only to Windows 2000 Basic Plus Plan Java chat room Secure Server access FTP access
Comments, Questions, or Additional Requested Add-ons:

*Payment Type:	MasterCard Visa Amex
*Credit Card number:	exp. date:
*Billing Cycle:	Quarterly Biannually Annually (Lower monthly rate)
Setup Charge:	All Hosting Accounts Include A Minimum Setup Charge, depending on your chosen Hosting 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.
There is a minimum three month contract on all hosting packages. All Hosting Packages automatically renew each billing cycle but can be cancelled with a 30-day notice prior to your next billing due date. 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. (Submission Is Secure) HOSTING POLICIES \| PRIVACY STATEMENT ©2001/2004 E-Market Media, All Rights Reserved

*Name:

*E-Mail:

Company:

*Street Address:

*City, State, Zip:

, , +4

*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, .us, .info, or .ws domain. (If you want to take advantage of our Monthly Special's FREE Domain Registration DO NOT register here first, just include your domain above and click the appropriate button in the "Monthly Special" field below.)

*Services Requested:

UNIX HOSTING ONLY
Please include the following add-ons (additional charges apply if not included with chosen hosting package)

Real-time audio/video     Java chat room     Volano chat room
Miva Merchant    Graphical referrer logs    mySQL server database
The below applies only to UNIX Basic Plus Plan
Front Page extensions    FTP access    Secure Server access

Windows 2003 Hosting Only
Please include the following add-ons (additional charges apply if not included with chosen hosting package)

Real-time audio/video Volano chat room
The below applies only to Windows 2000 Basic Plus Plan
Java chat room Secure Server access FTP access

Comments,
Questions,
or Additional Requested Add-ons:

*Payment Type:

MasterCard Visa Amex

*Credit Card number:

exp. date:

*Billing Cycle:

Quarterly Biannually Annually (Lower monthly rate)

Setup Charge:

All Hosting Accounts Include A Minimum Setup Charge, depending on your chosen Hosting 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.

There is a minimum three month contract on all hosting packages. All Hosting Packages automatically renew each billing cycle but can be cancelled with a 30-day notice prior to your next billing due date.

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.

(Submission Is Secure)

HOSTING POLICIES | PRIVACY STATEMENT