Forms - Customer Requirements Form:

Please provide the following contact information: 
(Click the first field then use tab key to move between form fields)

Title :   Mr, Ms, Dr etc.
Name :
Organisation :
Street Address :
Address (cont.) :
City :
State :
Post Code :
Contact Phone/s (H,W,M) :
E-mail :

 And information about the domain name you want and  forwarding details:
 
(Please clear unanswered or unneeded example fields below)  

 I have read, understand and accept your terms and conditions of service :   Yes / No ?
Domain Name Requested :
Domain name 2nd Choice :
Domain Name 3rd Choice :
  e-mail addresses required:
e-mail address 1 : @my-domain.com
e-mail address 2 : @my-domain.com
e-mail address 3 : @my-domain.com
** e-mail address 4 : @my-domain.com
** e-mail address 5 : @my-domain.com
miscellaneous details:
Forward Domain e-mail to :
* My Free Web-space is at :
* * My Web-space FTP is at :
* * My username is:
* My FTP password is :
 
  ** Suggest you have spam-trap addresses
   * These fields are needed only if you want us to upload your initial web-page
   * Just put your ISP's website address here along with your user name if you wish
      us to sort out these details.
       


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