MULTI-DATA SYSTEMS
5647 BELLE GROVE RD.
BALTIMORE, MD. 21225
410-437-9321
FAX 410-636-2221
1-800-TRY-MULT
DOMAIN NAME APPLICATION
COMPANY NAME ______________________________________________________
CONTACT PERSON ____________________________________________________
ADDRESS _____________________________________________________________
CITY _______________________ ST._____ ZIP __________
PHONE ________________________ FAX _______________________E MAIL _________________
DESIRED DOMAIN NAME
FIRST CHOICE: WWW. _______________________________. COM (max 19 characters)
SECOND CHOICE: WWW. _______________________________. COM
REGISTRATION FEE 30.00
SET UP DOMAIN NAME SERVER 75.00
TOTAL COST FROM MULTI-DATA TO SET UP DOMAIN NAME 105.00
THIS SERVICE DOES NOT PROVIDE INTERNET ACCESS.
Options: CHECK OFF OPTIONS DESIRED
BASIC DOMAIN NAME HOSTING: 14.95/mo. _______
Includes 5 Email Accounts, 5 megs of WEB space. 10 email alias, Free WEB Page.
Extra Email 3.00/mo. Ea. _______
Extra Web Space per 5 Megs 5.00/mo. _______
E Commerce Store up to 100 products or services 99.95 _______
E Commerce Store up to 500 products or services 199.95 _______
Authorized by:_______________________________ Title:______________Date:________________
CREDIT CARD (circle one VISA or M/C ) Card #:___________________________________________
Name on Card________________________________________ Exp DATE: _____________________