Personal/Contact Information

First Name
Middle Init. (Optional)

Last Name

Street Address
Apt/Suite

City
StateZIP Code

Telephone
Fax (Optional)

E-Mail Address
verify accurancy

Dial up ISP service request ( pick your plan)
unlimited dialup plan at $19.95 monthly ( 24.95 setup fee) ISDN 1-channel 64KB line 39.95/month (49.95 setup) ISDN 2 channel 128KB $69.95/month (99.95 setup ) ISDN dedicated 64KB $195.00/month (395.00 setup) ISDN dedicated 128KB $295.00/month ( 395.00 setup) skip to bottom

High speed dedicated access by Frame relay ( fractional T-1 or DSL)
Our network experts will call you to configure just the right equipment for these.

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Company Information (Optional)

Company Name

Address

City
StateZIP Code

Telephone
Fax (optional)

Contact E-Mail
fill in if different from above

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Server Information ( we only host Virtual domains)

Host Package Desired ( Setup fee includes domain name registration )
Choose One Domain server lite (5-10/MB/$45 per month) 100.00 setup fee Domain server profile (10-20/MB/$55 per month) 100.00 setup fee Domain server Pro (20-30/MB/$65 per month) 100.00 setup fee Domain server business (30-50/MB/$75 per month) 100.00 setup fee Commerce Server -regular (20-30MB/ $80/mo.) 150.00 setup fee Commerce Server -Deluxe (30-50MB/ $110/mo.) 150.00 setup fee Commerce Server -Premium (50-100MB/ $180/mo.) 150.00 setup fee

Domain Name Requested (full domain i.e, www.yourdomain.com)

Alternate Domain (in case first choice is taken)

My Domain is:
New (Request Multi-Tech to register my domain )
To be moved (I already have a registered domain name and will authorized Multi-Tech computer experts to fill out the InterNic forms have it moved)

I desire Microsoft " Frontpage 98" server extensions

I will want active server pages (ASP) with ODBC interfacing to my DBMS

Notes (please put any special notes that you think are important in assisting us in getting your server set up to run your special web applications.)

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Payment Information ( your card will be charged monthly)

Credit Card Type
Please Choose One Visa MasterCard

Card Number

Name on Card

Expiration Date (mm/yy)

By checking the box, I understand that the virtual server I am purchasing is to be billed at the rate published on the Multi-Techcx.com web site.  I also understand that billing is on a monthly basis, with my first month's bill being prorated based on the remaining days left in the month in which I am signing up for service. **Annual Pre-paid hosting fees are discounted 10% -call

Call our office 1-888-808-7472

If your need help learning how to browse ( surf ) the internet see our beginners guide section at our community center.