Cyberteknix Hosting - Order Form

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Order Form
To sign up for hosting and/or domain registration with Cyberteknix Hosting, please complete the form below. We will process your order and set up your account within a few hours. If you have any questions contact us through e-mail or phone (570)-278-9851. We are available 24 hours a day, 7 days a week through email. Once order for is received we will send an invoice to the email provided of the total amount.

Domain

	Register
	-Get your own .com, .net, .org, .biz, .info, .us for your site.

	Use Existing Domain
	-Keep your current registrar. -Point your DNS to Cyberteknix Hosting.

FREE

www.
(Type in your domain name)

First Name

Last Name

Company Name
Use your full name if this is not for a business.

Address

City

State/Province

Zip/Postal Code

Country

Phone Number

Fax Number (optional)

E-mail Address
Note: If you already have an account with Cyberteknix Hosting, be sure to use the same e-mail address for all accounts you set up.

Description of Site

Hosting Packages
Choose a hosting package, then select a billing cycle from its drop down menu (Monthly/Quarterly/Annually).

* A $19.95 one time setup fee will be added to Basic accounts, and $14.95 to Business and Deluxe accounts.

None (Domain Registration Only)

Basic
Business
Deluxe
Premier
Silver
Gold

Static/Dedicated IP
By default our Starter Hosting Package does not include a Static/Dedicated IP. If you are signing up for the Starter Package and would prefer to have a Static/Dedicated IP, please select "Yes" at right. If you are signing up for any other package, you may skip this option as a Static/Dedicated IP is included automatically.

Note: Selecting "Yes" for Static/Dedicated IP will add a $5.50 Monthly Fee to your bill and future invoices.

Yes No

Payment Method

Coupon Code
If you have a coupon code please enter it here.

Where did you hear about us?

If other, please specify:

Notes:
Use this section to list any additional requirements you have for your account.

Please type your full name in the box below. By doing so and submitting this form to Cyberteknix Hosting you are agreeing to the terms, conditions and acceptable use policy previously set forth by Cyberteknix Hosting.

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