Web Site/Domain
                                         Order Form

Agent Name: Ed Vita
Membership Number:
61226

Date: ____________

First Name: __________________________________
Last Name: __________________________________
(Owner of Domain for InterNIC Billing)
Company: __________________________________
Address: __________________________________
City: __________________________________
State: _________________
Zip Code: _________________
Day Phone: _________________
Day Fax: _________________
Fed or SS# _________________

Administrative Contact for Site:

First Name: __________________________
Last Name: __________________________
Email: ______________________________

Web Site Size:
___WebStarter 5 MB
___Standard Hosting 150 MB
___Commerce Hosting 300 MB
___Corporate Hosting 500 MB

Front Page enabled: yes/no

Domain Name Registration (new): www.________________________________

Domain Name Modification (transfer): www._____________________________

Credit card number: ________________________________
Credit card type: ___________________
Name as it appears on card: _____________________________________
Expiration date (month/year): ______________________