First name
Last name
Middle initial
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
Current E-mail
Current URL

Please provide the following ordering information:

CyberTec Web Hosting Services

	Plan #1: 5 MB "Do It Yourself" - $15.00/3 Months
	Plan #2:  10 MB "Do It Yourself" 1 Email - $30.00/3 Months
	Plan #3:  10 MB "Do It Yourself" 5 Email - $45.00/3 Months
	Plan #4:  10 MB "Domain Forward-Do It Yourself" 10 Email -  $75.00/3 Months
	Plan #5:  25 MB "Domain Premium-Do It Yourself" Unlimited Email -  $105.00/3 Months + $30.00 Set Up
	Plan #6:  10 MB "Support" 10 Email - $144.00/3 Months
	Plan #7:  10 MB "Domain Forward - Support" 10 Email -  $174.00/3 Months
	Plan #8:  25 MB "Domain Premium-Support" Unlimited Email -  $204.00/3 Months + $30.00 Set Up
	Plan #9 "Custom Plan"  Let Us Know What You Need ! Please Provide Special Ordering Information Or Instructions Below.

CyberTec Account Information

Account Username Requested
Password Requested
Password Re-Entered

Microsoft® FrontPage® Server Extensions

	I will be using Microsoft ® FrontPage® to publish my web site.  Please install FrontPage Server Extensions in my directory.
	I will be using Ftp to publish my web site.  I do not need Microsoft® FrontPage® Server Extensions installed in my directory.

CyberTec E-mail Services

1 to 10 E-mail Accounts Included in Hosting Plans #2 to #8 - Free

Unlimited pop/smtp E-mail Accounts - $9.00 / 3months per E-mail

 

Please Specify Names Of E-mails Accounts Wanted	Please Specify Password	If Wanted, Please Specify Existing E-mail Address To Forward This Email Account To
Email #1   Email #2   Email #3   Email #4   Email #5   Email #6   Email #7   Email #8   Email #9   Email #10	Password #1 Password #2   Password #3   Password #4   Password #5   Password #6   Password #7   Password #8   Password #9   Password #10	Forward #1    Forward #2    Forward #3    Forward #4    Forward #5    Forward #6    Forward #7    Forward #8    Forward #9    Forward #10

 

CyberTec Domain Name Services
(Only use this section for Domain Accounts - Plans # 4,5,7,8)
 

	New Domain Name Internic Registration - $70.00/1st 2 Years
	Transfer Domain Name Internic Registration - Free

 Main Domain Name Included In "Domain" Hosting Plans - Free

Unlimited Secondary Domain Names - $30.00/3 months

Please Specify Domain Names

Domain #1    Domain #2    Domain #3

CyberTec Web Services

	Web Site Design Service - $380.00/10 Hours
	Unlimited Local Dial Up Internet Service - $60.00/3 months
	Cybertec Resumes Online - $15.00/3 months

CyberTec Additional Web Space

Additional MB

Unlimited web space available 10 MB - $15.00/3 months 25 MB - $30.00/3 months

CyberTec Payment Information

Please provide the following payment information:

Credit card	MasterCard Visa American Express Discover
Cardholder name
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Expiration date  (mm/yy)