Web Hosting Request Form Order Number Step 1. CHOOSE YOUR ACCOUNT Account Type Basic Account – $9/month or $90/year Business Account – $14/month or $140/year Pro Account – $29/month or $290/year Step 2. DOMAIN NAME INFORMATION Domain Registration * New Domain I already have a domain name and will keep it with my current registrar I already have a domain and wish to transfer it to Clearlight Domain Name * Alternate Domain Name Step 3. CONTACT INFORMATION Company Name First Name * Last Name * Email Address * Address * City * State/Province * – Select Province/State – Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip/Postal Code * Country * Phone Number * Step 4. BILLING INFORMATION Payment Method * — Select Payment Method — Credit or Debit Card Check or Money Order Credit Card Type — Select Credit Card Type — Visa Mastercard American Express Discover Credit Card Number Credit Card Expiration Date Credit Card CVC Name of Card Holder Credit Card Billing Address Credit Card Zip Billing Service Period * — Select Service Period — Automatic Monthly Credit Card Billing Quarterly Invoice 6-Month Invoice (7th month FREE) Annual Invoice (11th and 12th months FREE) Step 5. BILLING CONTACT (if different than the primary contact) Billing Contact Name Billing Contact Mailing Address Billing Contact Phone Number Billing Contact Email Address Comments / Special Needs Please read our Terms & Conditions before placing your order. The data you provide is secured through SSL and PGP.
