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Domain & Hosting Application Form

All fields marked with a * are required.

Please sign-up online before you proceed with your payment, so that we can have the necessary information in setting up your desired services. All information provided in this form will be forwarded to our process queue after submission.

NOTE : WE WILL NOT ACCEPT ANY WEBSITE/HOSTING SETUP IF THE INFORMATION REQUIRED IS NOT FULLY PROVIDED. THIS INCLUDES LANDLINE NUMBERS, FULL ADDRESS, AND AGREEMENT OF TERMS EVEN IF WE HAVE ALREADY RECEIVED THE PAYMENT.

ALSO, WE WILL REQUIRE THE FAXED DEPOSIT SLIP OR SMART MONEY RECEIPT BEFORE SETUP BEGINS.

APPLICANT INFORMATION
Company Name
Company Address
Zip Code
Contact Number*		Fax Number
Name of Contact Person*
Position in the Company
Existing Email Address*
Mobile Number
BILLING INFORMATION
In charge of Payment
Position
Billing Address
Billing Email Address *
Billing Contact Number		Billing Fax Number

DOMAIN REGISTRATION INFORMATION
Domain Name*	URL of your Website e.g. www.google.com
	* NOTE : Please fill up the Domain Name Information even if you will be signing up with another registrar. We still need the information to setup your website.
Required*

HOSTING PACKAGE
Web Hosting Plan*
Additional Note for Izekhosting
Terms and Condition*	Yes, I agree to the terms and conditions.
I am an Existing Customer
Discount No If there are any