Internet Services > Sign-Up Form > Web Site Hosting

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Application for Domain and Web Hosting Services

Contact Information

Contact Name:
Organization Name:
Address:
City:
 State:
 Zip code:
Billing Contact, if different from Contact Name above:
Billing Address, if different from address above:
Billing Address City:
 State:
 Zip code:
Day phone:
 Evening phone:
Fax:
 Other e-mail:

How did you learn of PatriotNet?
If referred, by whom?
Sales Representative:

Web Development Service Desired?

Consultation Request: Check if interested in PatriotNet Web Development services, to be billed at $75/hour.

Web Hosting Service Desired

Hosting Package:
Domain Name:

Enter a domain name (no more than 23 characters in length) followed by .com (businesses) or .org (organizations):

first choice
 second choice
InterNIC domain name registration fees billed separately by Network Solutions, Inc.
Register or Transfer?
Dial-up Account Username:

Please choose a username between three (3) and eight (8) characters in length, containing only numbers and lower-case letters, and beginning with a letter. 

first choice
 second choice
Operating system:
If "other", please specify:
Comments:

Payment Choice

Cash

Cash payments must be made in-person at the PatriotNet offices.  Payment must be received before services will be activated.

Check

Payments by check must be mailed or made in-person at the PatriotNet offices.  Checks should be made payable to PatriotNet.  Payment must be received before services will be activated.
PatriotNet
9990 Fairfax Boulevard, Suite 500
Fairfax, VA 22030

Credit Card

Card:
Name on card:
Card Number:
 Expiration:
Charge this card automatically at the start of each new term.
Mail me a bill before the start of each new term.

Cardholder Address

If the cardholder's address is different from the address given in the Contact Information section, above, please supply the cardholder's address below.

Address:
City:
 State:
 Zip code:

Call PatriotNet at 703-691-8122 with questions