Order Form

Account Type

Hosting Plan
Do you want Internet access for $19.95/mo. (The $20 setup fee is waived when you sign up for a hosting account)	Yes Check for a local dialup number
Is the Domain Name a new registration or a transfer?	NewTransfer

Account Features

Do you need FrontPage extensions installed?
Do you need ASP.NET installed ?	No 1.1 2.0
ODBC data source (DSN)?
Install DOTNETNUKE

Account Information

Domain Name See if your domain is available
Will Wired Hosting be handling the domain name registration/transfer?	Yes
Requested User Name
Password
Day Time Phone Number
Evening Phone Number
EMail Address
Where did you find us?
Additional Comments

Billing Information

Organization (Optional)
Form of Payment
Credit Card Number
Expiration Date
Name as appears on Card
Credit Card Billing Address
City, State, Zip
Country
Billing Cycle:

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