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SECURE ONLINE ORDER FORM

Please use this form to place your order online via our secure server connection. All the information you provide on this page will be automatically encrypted by the system and transmitted via secure SSL channel.

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WARNING TO PERPETRATORS OF CREDIT CARD FRAUD:
Our Order Processing representatives will verify personal information and credit card validity for all new customers before processing the order.  This transaction will also automatically detect and include the unique Internet IP address provided by your dial-up service, ISP, company or college...

SelfNET™ Dedicated Server Package
Selection Price Quoted Description
$   

Monthly Dedicated Server Hosting Plan, including
- free server hardware (as quoted by SelfNET)
- free server setup and installation services
- unlimited bandwidth and traffic

* Required information fields
* First Name:
* Last Name:
* E-mail:
Domain Name:
  • If you do not have a domain name to use with your web server and E-mail services, please click here to register your domain name online.
* Customer ID:
  • If you do not have an account with SelfNet or your Customer ID, please leave the Customer ID field blank and complete the rest of the form:
Company:
* Phone / Ext.: X
Fax:
* Address:
* City:
State:
* Postal Code:
Country:
* Credit Card:
* Card Number:
* Exp. Date: please use format:   "MMYY"
* Card Security Code: 3-4 digit code - please click here for help
Please type any special instructions or comments in this box:
To submit your order now, click on the "Accept..." button below.
All the information you provided will be automatically encrypted
by the system and transmitted to SelfNet Order Processing.

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