Level E Request Form

Section 1 - Customer Data

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Contact Name:

Business Name:

Type of Business:
If other, please specify:

Business Address:

Address:
Apt. or Suite:
City: State ZIP Code

Country:

Daytime Phone:

Other Phone:

Fax Number:

E-Mail address:

Are you a current customer? Yes No

If no, were you referred to us by someone?

Section 2 - Account Data

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Account Name:

Password:

Domain To Register (max 28 characters, not including domain type):

New Domain or Modified Domain?
New Modified

Alternate Domain To Register:

New Domain or Modified Domain?
New Modified

Microsoft Frontpage Extensions: Yes No

Secured Server Access: Yes No

Section 3 - Financial Data

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Level E Hosting Package:
A. Level E Hosting Package Setup Fee
B. Level E Hosting Package First Month
C. Total Now Due for a Monthly Account
 $100.00
$700.00
$800.00

Section 4 - Payment Data

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I will be paying by:
Check Money Order Credit Card

If Paying by Credit Card, we accept 

Visa, MasterCard and American Express
To pay by credit card for your initial payment or your monthly payments, you will have to fill out our Credit Card Authorization Form. This form MUST to be signed and faxed to us before we can begin to process your account.
 Click here to get our Print-and-Fax Credit Card Authorization Form.
When you have printed the form, click on the BACK button to return to the Online Order Form.

Credit Card Number: Example: 1234-5678-1234-5678

Expiration Date: Example: 01/97

I wish to be billed each month for my account by:

Automatically billing my credit card each month
Mailing me an invoice to the address above

Section 5 - Additional Information

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Additional Domain Names
New Modified
New Modified

E-Mail forwarded off site?
Yes No

If "Yes", E-Mail Address to forward to:

I have read and agree to the Acceptable Use Policy http://www.datamg.com/aup.html
This field MUST be marked "YES" for your account to be processed

I have read and agree to the Billing Policy http://www.datamg.com/hosting/billing.html
This field MUST be marked "YES" for your account to be processed

I have read and agree to the Usenet News Policy http://www.datamg.com/disclaimer.html
This field MUST be marked "YES" for your account to be processed

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