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Premier Service Account Order FormContents

 
 
 
 
 
 
Please provide the following ordering information: 
QTY
DESCRIPTION
BILLING
Credit card
monthlyannually
Cardholder name
Card number
Expiration date
SHIPPING
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Select any of the following options you would like added to your account: 
Domain Name Registration ($30 ea. does not include Internic fees) 
Additional Pages ($50 setup plus $5 per month ea.) 
Streaming Multimedia (call for current quote) 
Database Connectivity (call for current quote) 
Online Ordering ($30 setup plus $10 per month ea.) 
Additional Email Forwarding Accounts ($30 setup plus $10 per month ea.) 
CGI Forms ($30 setup plus $10 per month ea.) 
Other (call for quote) 
Please provide the following contact information: 
Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail
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Last revised: March 31, 1998