MIS Virtual Webserver Signup Form

THIS PAGE IS SECURE

Fill out the following fields with the information we need to help you.
Shortly after your submit this form a copy of it will be automatically e-mailed to you.
We will respond via email in a timely manner. Thanks!

* Donotes a Required Field

Billing/Contact Information

*First Name:

*Last Name:

*Organization Name:

*Billing Address:

*Email Address:

*Phone Number:

Comments:

Please tell us the desired domain name you would like. If you would like to check domain names first please call us. You can also put alternate choices in the comments section above.

Domain Information (All Fields Required)
* Desired Domain Name:	www.
*Number of Years:	($20 per year for domain registration if not registered)
*Type of Service:	VWeb Service($35) VWeb Basic($20) Domain-Lite($12 ) To Hold Only Forward Domain
* Desired Username:	8 Character Max / Must start with letter
* Desired Password:	8 Character Max / Must start with letter
*Password Again:	8 Character Max / Must start with letter

It is absolutely essential that you record the username and password that you choose. This information is secure, and will not be given out later. Accounts that must be reset due to loss of username and/or password on behalf of the customer may be subject to additional fees. We can not stress enough that you do record that information in a safe and secure place.

It is strongly recommended that you print out this page (with all of the information filled in correctly), and save it for your records. You can do this by taking advantage of the "Print" function of your browser. This should be located under the "File" menu at the top on both Windows and Macintosh computers.

By clicking the submit button I am instructing Midcoast Internet Solutions to register the domain. I have read the MIS Web Hosting Service Policy I also indicate that I have read through the hosting information and I understand the service and charges involved. If you do not understand or have additional questions please call Midcoast Internet Solutions at 207-594-8277.