BizzCity - On-line domain name order form

Online Order Form: ( * not required )

Please Note: Domain registration is FREE only to customers hosting with us. This domain name registration form (Online Order Form) will be processed as soon as we receive an approved order for one of our monthly web site hosting services. Visit our Web Site Hosting area for complete details. We look forward to seeing your new web site on the net.

While our service is free, the domain registration company will bill you $70.00 for the first 2 years, then $35.00 a year thereafter for each domain name registered through them.

Domain Name to register:	.

Your E-mail Address:

Organization (Registrant) Information:

Organization Name:
Organization Address:
City:
State:	ZIP:
Country:
Phone:	- *Ext:
*Fax:	-

Billing Contact Information: (Information required for domain registration company)

Name(last, first):
Type of Contact:	Individual Role Account
Organization:
Street Address:
City:
State:	ZIP:
Country:
Phone:	- *Ext:
*Fax:	-
E-mail Address: