CIIC  Web Site Order Form

Please fill out this form completely and click the Accept Order button.

If you have any questions, please call us at 1-818-591-7825
or E-mail us at sales@ciic.com.

If you do not have a Domain name you must register that first.
You must return back to this form after registering your domain.

Web Hosting Order Form:

Note: We record your IP address and Host Server Name
for credit card fraud tracking purposes.

* means it's a required field

Where Did You Hear About Us?

*Accept Terms of
Service Agreement

Yes
No (click here to read it)

*Domain Name:
(www.yourname.com)
*Your Full Name
(First & Last)

*Choose your User Name:
(must be 6 to 10 characters - all lower case with numbers and letters only - no spaces or other characters - subject to availability)

*Choose your Password:
(must be 6 to 10 characters - all lower case with numbers and letters only - no spaces or other characters)

*Choose Hosting Plan:

Hosting Plan One Time
Setup Fee
Basic (Plan 1): 300 MB, $19.95/mo... $239.40/year $49.95
Premium (Plan 2): 600 MB, $29.95/mo... $359.40/year $49.95
Enterprise(Plan 3): 900 MB, $59.95/mo... $719.40/year $99.95

Any Special Instructions?

 

Web Site Features:

Do you need SSL encryption?
(Enterprise Plan Only)

 Yes No

Do you need us to design your site?
(additional fees will apply)

Yes No

Customer Information:

*First Name:

*Last Name:

*Company Name:

*Address #1:

Address #2:

*City:

*State/Province:

*Zip/Postal Code:

*Country:

*Phone Number:

*Fax Number:

*Your Current E-mail Address:

Payment Information:

*Select Payment Type:


Site will not be live until payment arrives and clears if paying by check.
If you choose to by by credit card we will call to verify your information and process your payment.

When you click below, you are agreeing
to the terms stated in the SERVICE AGREEMENT.
(You may choose to print this agreement)