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.

Credit Card Number:

Credit Card Expiration Date:

Exact Cardholder Name:

Credit Card Billing Address:

Billing Address Line 2:

*Billing City:

*Billing State/Province:

*Billing Zip/Postal Code:

*Billing Country:

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