Contact Information:
Name: ________________________ Company:____________________
Address:_________________________City____________State___ Zip:_______
Phone:___________________________FAX:_____________________________
E-mail address:______________________________________________________

Account Information:
(Primary username is for both FTP and Email. Additional usernames are for email only)
Primary Username:__________ Password ___________ Forwarding: _______________
2ndary Username:__________ Password ___________ Forwarding: _______________

Directory or Domain name requested: ________________________________________
(Check at Better-WhoIs.com)

Virtual Host domains may enter up to 5 Keyword Aliases at no charge. These are names of the form Keyword.YourDomain.Com, that point to your main home page.

For example, if your domain name is realestate.com, it might help you to get the additional keyword alias of properties.realestate.com

Keyword aliases (Virtual Host accounts only):

_____________________________
_____________________________
_____________________________
_____________________________
_____________________________

Please Select the Account You would like

Type of Access	Setup Fee	Price Per
_____ 50Mb Virtual Host yourdomain.com weekly usage reports cgi-bin scripts Webglimpse full-text search public FTP area mSQL database Cybercash software Stronghold secure server Minivend shopping cart 5 Keyword domain aliases 5 POP accounts Unlimited e-mail forwarding http://YourDomain.com	Registration: $20	$25/mo or $250/yr

(Single License Only -- Resellers please call for information)

Each account may be used by one commercial customer or business. Please provide payment for the setup fee OR yearly fee for each account requested. The setup fee is waived if the year is paid in advance.

Total Amount: ______________________   Date:  _______________  


PAYMENT METHOD:

 _____  Please bill me at the address above

 _____  Please call me to arrange payment

 _____  MasterCard (16 digits) 

 _____  VISA (13-16 digits)


CREDIT CARD NUMBER: _________________________

Name on card:       _________________________

Exp. Month: ________  Exp. Year: ____________


Who will maintain this site? ________________________

How did you hear about us?   ________________________

Comments:
     _____________________________________________

     _____________________________________________

     _____________________________________________


Signature: _______________________________ 


Please mail or fax this form to:

Internet WorkShop
212 S. Meridith Av
Pasadena, CA 91106

 / 520-440-1420 / (FAX) 792-7377