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 Your Name:
 First Name:  Initial:  Last Name:
     
 Your Address:
 Company Name:
 
 Type of Business:
 
 Street:
 
 City:  State/Province:  Zip/Postal Code:
     
 Daytime Phone:
 
 Home Phone:
 
 Fax:
 
 E-Mail Address for Domain Registration:
 
 E-Mail Address to send Account Information to:
 
 Billing Address: If not the same
 Billing Name:
 
 Billing Street:
 
 Billing City:  Billing State:  Billing Zip:
     
 Billing Phone:
 
 Billing E-Mail:
 
 Domain Name:
 Domain Name: Check Domain Name
 
 Domains are registered for $15 USD per year.
 Domain name is already registered:
 Web Hosting Account Option:
United States Bronze $10.00/Month $10.00 Setup $20.00 Total
United States Silver $15.00/Month $30.00 Setup $45.00 Total
United States Gold $20.00/Month $30.00 Setup $50.00 Total
United States Platinum $25.00/Month $30.00 Setup $55.00 Total

Canadian Bronze $15.00/Month $15.00 Setup $30.00 Total
Canadian Silver $22.50/Month $45.00 Setup $67.50 Total
Canadian Gold $30.00/Month $45.00 Setup $75.00 Total
Canadian Platinum $37.50/Month $45.00 Setup $82.50 Total
NOTE: Your Domain Registration fee ($15 USD)
is not included in the above charges.
 Password for your account: (6-8 Characters in length)
 
 Payment Method:
 Check (Web Whirls will set up your account upon receipt of your check)
      Please Remit Payment to:
      Web Whirls
      1015 Regent St.
      Fredericton, N.B.
      Canada
      E3B 3Y9
 Visa
 MasterCard
 All domain name registries require Credit Card info to register domain names.
 Credit Card Number:
 
 Expires:
 
 Name as it appears on Card:
 
 Credit Card Billing Address Zip Code:
 
 
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