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Web Hosting Order

Please fill out the order form below and click on the "Send Order" button, your account will be configured within48 hours of the submission of this form.

New Customer Information Form
Value price:	US$19.95 per month

First name:
Last name:
Email address:
Business name:

Mailing & Contact Information
Street address:

City:
State:
Zip/postal code:
Country:
Phone number:
Fax Number:
Domain Name Registration
Check to see if your desired domain name is already taken by clicking here!
Register Type:	Create a new domain name. Move domain.
Domain name: (1st choice):
Domain name: (2nd choice):
Password?	(Must be 8 characters upper and lowercase with numbers)
Option:	Install Frontpage ext. Java Chat $7.00/month.
Please note that InterNIC will bill you directly for Domain name registration. The current registration rate is $35.00 per year and the first two years must be paid within thirty days of domain activation.
Payment Information
TotalAd accepts payment in the form of a Bank Check (or International money order) as well as by Mastercard, VISA and AMEX. For credit card payment, you will be charged for the a US$30.00 setup fee; You will then be billed US$19.95 every thirty days from the activation of your Web presence for the upcoming month's service. Your account will be configured within48 hours of the submission of this form.
Payment method:	Mastercard/VISA/AMEX Bank Check/Money order.
. For check or money order payment, you are asked to send payment for the first three months of service (US$59.85) plus a US$25.00 setup fee (total payment: US$84.80); You will then be billed every three months for the upcoming quarter's service. You will be activated on receipt of payment. * Your credit card will be automatically billed for the amount of US$19.95/month in Australia dollars based on the exchange rate at the time of billing.
Credit Card Information
If you are paying via Credit Card, please provide your credit card information below.
Card Number:
Expiration Date:
Cardholder Name:
Cardholder Phone Number
Cardholder Full Address:
Mailing a Check or Money Order
Please make checks payable to "TotalAd" and mail to the following address:
TotalAd 80/83-93 Dalmeny Ave., Rosebery NSW 2018 Australia Fax:(US) +1 419 793 8312 (AU) +61 2 9663 3659
Thank you for your interest!

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