Duffy Infodesign: Hosting Order Form

Customer Information
First Name
Last Name
Company
Please put your name above if there is no company name.
Billing Address
City
State
Zip Code
Country
Phone
Primary E-mail
Offsite or backup E-mail
Repeat your email address above if you do not have a secondary E-mail account.
Billing Information
Billing Method
For check / money orders, simply fill out this form then print mail it or fax it to us. If you have chosen to pay by credit card we will contact you shortly to obtain your billing information. Also, if you have any difficulty using this form you may e-mail us at Info@DuffyInfodesign.com to have us process your request.
Account & Domain Name Information
Account Type
Billing Frequency
Choose a User Name*:	(maximum 8 characters)
*The user name must start with alpha characters and consist of lower case alpha characters, numeric characters, the minus sign "-" or underline "_".
What is your domain name?	www.
Please choose one of the following:
This is a new domain name - please purchase for me. (Monthly accounts will be charged $20 for 1 year registration.)
I already own this domain name.