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Because of the unusually high amount of credit card fraud on the internet we are now requiring a copy of your picture identification and the front and back of your credit card. Please fax these to 409-793-1860 or send as an attachment to newservers@diyhosting.com before placing an order. Orders will not be filled without the above information.



Server Name (anyname.domainame.com)*
Name servers will be created using the servername. If your servername is server01.xyzhosting.com then your primary name server would be ns1.xyzhosting.com. If you do not want name servers created Check Here

Company Name
Company Type (LLC, Corporation, etc.)
Primary Contacts First Name*
Primary Contacts Last Name*
Primary Contacts Title
Address*
City*
State / Province*
Zip / Postal Code*
Email Address*
Home Telephone Number*
Work Telephone Number
Fax Number

Special Requests

Payment Information - Our firm will be paying for the products and services shown above (start-up and recurring fees) in the following method:
Paypal
Corporate or personal credit card
Name on Card*
Card Type*
Card Number*
Expiration Date*

This document will not be "signed" in the sense of a traditional paper document. To verify the contents of this form, the signatory must enter any combination of alpha/numeric characters that has been specifically adopted to serve the function of the signature, preceded and followed by the forward slash (/) symbol. Acceptable "signatures" could include: /john doe/; /jd/; and /123-4567/. For example: if your name is John Miller, you could type /John Miller/ below.
Electronic Signature*
Date*
Fields marked with an () are required. Fields marked with an () are required only if paying by credit card.


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