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 order form

*Domain Name: www.
           please include extension .com, .net, .org, etc
*Domain Registration:
*Customer Name:
first name
last name
  Address 1:
  Address 2:
  City, State, Postcode
City
State
Postcode
  Country:
  Phone Number:
*E-mail:
*User ID (Max. 8 characters):
*Password (Require 8 characters):
*Confirm Password:
*Hosting Plan / Billing Cycle:
  Domain Purchase:
$15 / One Year $30 / Two Years
  Where did you hear from us?
  Comments:
(*) Required Field
Secure Transaction via paypal:
Authorized Credit Cards
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