PERSONAL INFORMATION

Name (first, last):__________________________________________________________

Address:_________________________________________________________________

City:________________________________ State/Province:_______________________

Postal Code:__________________ Country (if other than U.S.):____________________

Telephone:_____________________________ Email:____________________________

How did you find us? ______________________________________________________

ACCOUNT INFORMATION

Account Status (check one):

[   ] I want to open an account with a new virtual domain name.
[   ] I want to transfer an existing virtual domain to EdgeWorld.

Your Domain Name:

http://www.____________________________________ Ex. http://www.yourname.com

A Login ID and Password are required when you connect to the EdgeWorld server in order to upload/download files to your site.

User Login ID:_____________________ Password:_____________________

Service Plan (check one):

[   ] SOHO/PERSONAL at $4.95 monthly; $0.00 (FREE) initial setup fee
[   ] ECONOMY at $9.95 monthly; $10.00 initial setup fee
[   ] BUSINESS STARTER at $19.95 monthly; $25.00 initial setup fee
[   ] BUSINESS PRO at $39.95 monthly; $35.00 initial setup fee

Number of Months: ________

Other:

[   ] Check here if you would like Microsoft FrontPage 98 extensions installed.

PAYMENT INFORMATION

Payment of initial setup fee and first month of hosting is due upfront. Contracts of 6 months or more receive a discount of $10.00 off the setup fee but you must pay for 6 months of hosting upfront.

[   ] Check
[   ] Money Order

For Credit Card orders, please use the Online Ordering page.