Web Site Hosting Application Form

Contact Information

Your Name:
Organization:
Email:
Street Address:
City:
State/Province:	Zip:
Country:
Telephone:
Fax:

Account Information

Purpose of this Web site:

Please specify a user name which you will use to log into the server with to maintain Web site. The username must consist of 6-8 lower case letters and not contain any punctuation.

Username:

Please specify a password which you will use to gain access to Web site. For security reasons, the password MUST be constructed to meet the following requirements:

The password must have eight characters.
The password must contain at least two alphabetic characters, at least two numeric character, and at least two special characters (punctuation).
The password must not resemble the user's login name or any reverse or circular shift of that login name.
The password must not contain the user's initials.
The characters of the password must not be able to be re-arranged to form a name, place, thing, or any word that can be found in the dictionary.

The password supplied below must meet each requirement stated above, or your application will be rejected - no exceptions .

Password:

Domain Information

You are responsible for contacting a domain registrary such as Network Solutions, Godaddy, or Register.Com to register or move your domain.

Important instructions for registering the domain with the correct primary & secondary DNS server hosts, IP addresses, and the technical contact zone contact information will be displayed after this form is submitted.

Domain Name (i.e yourcompany.com):

Domain Registration (check the one that applies):

New domain, I will Register
Existing Domain, I will move the domain myself

Web Site Features Desired (select one):

I would like my web site hosted on a UNIX Apache web server which includes access to the following available options:

MySQL Database

CGI

perl

PHP

Java Servlets

I would like my web site hosted on a Windows 2000 IIS 5 web server which includes access to the following available options:

FrontPage 2002 Server Extensions

SQL Server or Access Database

ASP

Any requirements for Secure Socket Layer (SSL) capabilities require an annual SSL certificate (must be purchased from Thawte/Verisign)

** NOTE: This form may take several minutes to process. PLEASE do not click the submit button more than once.