Package #3
Virtual Domain Hosting
      Request Form

All fields must be filled in. Organization: Address: City: State:      Zip Code:         E-Mail Address: (Enter "None" if you don't have one.) Day Time Phone Number: (Don't forget the Area code) Briefly explain your Organization: Contact Person: E-Mail Address: (Enter "None" if you don't have one.) Day Time Phone Number: (Don't forget the Area code) Your Domain URL: (Example, www.your-name.com) Have you already registered this name.      YES       NO   If the above is "NO", Do you want us to register it for you.      YES       NO   Please place additional instructions in the box below. (The box will expand as necessary) I have read and understand the "Terms and Conditions" set forth by Bronson-tate.net. I agree to abide by them. Yes, I Agree   No, I Disagree             Price for Package 3 is as follows:    $17.95 per month for disk space and access. + $60.00, one time set up fee.    $77.95 Total, due upon completion of setup.