Set Up Domain Name Account and/or web Hosting Account

WebRJDesign

WEBSITES THAT WORK

Website Services:
Web hosting, domain name registration, custom web design and development, database programming, dynamically generated web pages.

Telephone: 631-730-6491
Email: webrjdesign@yahoo.com

• Web Design reasonably and affordably priced

• Web Hosting starting at $13.95 per month ($10.50/month for church or ministry)

• Domain Name Registration $16.00 per year

• Search for Domain Name

FAX

Set Up an Account for
Managing Your Domain Name(s)

FAX

To set up an account for managing your domain names, you may either:
- Fill out, print, and fax this form to have us set up your domain account for you, or
- You may create your own domain account: FAQ Create Account

* PLEASE NOTE: Fields with '*' are required when the actual domain name account is created.

* Username:
(6-15 chars)

* Password:
(6-15 chars)

* Password Question:
(Selection of password question cannot be changed once your domain account is created.)

	Select one password question:
	What is your favorite pet's name?
	What is your favorite color?
	What is your mother's maiden name?
	What was your first car?
	What city were you born in?
	What is the name of the high school you graduated from?
	What are the last four digits of your credit card number?

* Secret Answer:
(Your secret answer cannot be changed once your domain account is created.)

Company Name:

* Name (First, MI, Last):

* Address:

Apt/Ste

* City, State & Zip:

* Country:

* Telephone:

e.g. (555) 555-5555 x555

Fax:

* E-Mail:

There are 4 separate categories with regard to names and addresses on the domain name account:
   Registrant: Person who owns the domain name
    Administrative contact: Person who manages the account for the domain name
    Technical contact: Technical person, usually the same as the administrative contact
    Billing contact: Person whose credit card is being used to register or renew the domain name

The Administrative and Technical contact is often the same person. The Registrant (person who owns the domain name) may be different from the Billing contact (person whose credit card is being used for payment).

Use the information above for the Registrant / Organization Contact information.

Select One

Only the Administrative Contact (and Billing Contact) receives e-mail notification for Domain Name renewal.

(Recommended)

Have us be your Administrative Contact.

Use the information above for the Administrative Contact information.

Use the information above for the Billing Contact information.

(Recommended)

Have us be your Technical Contact.

Newsletter Options

Would you like to receive product updates and other company information?	Yes No
Email format preference	HTML Plain Text

Do you want your contact information available to others?

Yes No

(Mandatory) *

I agree to the terms and conditions of the user agreement.

Domain Name Registration
($16.00 fee is non-refundable when domain name is created)

Enter Domain Names
Start by checking your domain name availability. Please enter one domain name per line without the "www". (For example, enter "mydomainname.com" and not www.mydomainname.com). If your domain names are available for registration, you will be requested to provide nameserver and payment information.


Registration Period: (years)	1 2 3 4 5 6 7 8 9 10

Credit Card Payment Information (Billing Contact)

Card Type:	Master Card Visa American Express
Card Number:	e.g., 4123-4567-8910-1234
CVV2: (Card Verification Value 2)
Name (exactly as it appears on Credit Card account):
Expiration Date (MM / YYYY):	/

Address (exactly as it appears
on Credit Card account):

Apt/Ste

City, State & Zip
(exactly as it appears
on Credit Card account):

Your Signature and Date: