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ORDER WEB HOSTING

Fill in this form to order Web Hosting
Note: fields marked with a " * " are required.
If you get an error using this form, please email info@SecureHostingService.com directly.
Order Information
* Domain Name (yourname.com)
Check to register this name as a new domain name
* Web Hosting Plan
See the plans here
* Payment Method
Paypal or moneybookers preferred.
If Other, enter preferred payment method below in Comments.
Any special commetns or instructions for your Account?

Payment Information
* Payer Name
For Paypal or Moneybookers this is the accountl email address.
Credit Card Number:
Expiry date:
MM/YY (eg. 12/07)
CVV2 number:
3 digit number on back of card

Account Information
* Your Full Name
* Email Address
This is where account details are sent
Backup Email Address
Company Name / Organization Name
* Contact Telephone Number
Mail Address
Country
How did you hear about us?
(eg. Google, Yahoo, magazine, etc)

Online Signature
Agreement to Terms
By typing your name in the Online Signature box and pressing the "Submit Order" button below you hereby agree to all of the Terms of Service and Acceptable Use Policies, and hereby authorize the billing of all related charges for this account.
* Online Signature:


 
 

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