Web Hosting Request Form CompanyStep 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 –AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 NeedsPlease read our Terms & Conditions before placing your order.The data you provide is secured through SSL and PGP.
