Form for requesting a web site setup

Form for Requesting a Web Site Setup
(Purchase a domain name first. One option for this is aaadomainregister.com. )
We provide free domain service if purchasing hosting service for a year at a time.
Completing this form and submitting it cost you nothing. This just supplies us with the info for setting up your web hosting site. To start your hosting, mail the appropriate hosting fee to this address; but use this form to email usthe information to set you up.

Oregon Professional Microsystems
20020 Marigold Ct. #24
West Linn, OR 97068

Phone: (503) 697-4773
Cell: (503) 952-6045

Customer Information

*Required Fields

Name*

Company

Please put your name above if there is no company name

Billing Address*

City*

State*

Zip Code*

Country*

Phone*

I agree to abide by the policy of this hosting site: * Yes

Primary Email*

Offsite or backup Email*

Repeat your email address above if you do not have a secondary email account

Account & Domain Name Information

Choose Web Hosting Plan:*

Choose a User Name*#: (maximum 8 characters)

#The user name must start with alpha characters and consist of lower case alpha characters, numeric characters, the minus sign "-" or underline "_".

What is your domain name?*
www.

The form requires at least a version 6 of the Microsoft Internet browser, which included new security features. It will not work with IE5. If your browser does not support this form and you don't want to update your browser, (1) complete the form (without submitting) (2) and use Ctrl/A to select the entire form with your input. (3) Then use Ctrl/C to put it in the clipboard. (4) Then paste it to an email to send to us. The sure the complete data for each field is emailed to us.