1) Your Details
Salutation Name Surname
 
  Company
     
  Position
     
  Address
   
  City
  State     Zip Code 
  Country
  Phone (international format eg +61......)
  Fax (international format eg +61......)
  Mobile (international format eg +61......)
  Email
Email 2
2) Your Order
I would like to order the Plan.
Domain Name :
   
With these Extra's (tick if required)
 IP Based Hosting ($5 setup & $5 / mth )
  MySQL Database ( $3 / mth )
 SSL Directory ( Free with IP Based Hosting )
 Reseller Account ( $20 Setup + $20/mth)
I would like to prepay for Months of hosting
SPECIAL : if you pay for 12months you get an extra month free
Note that I would like to claim the following discounts;
12th Month Loyalty Bonus ( 1 extra month free )
Transfer from another host* ( 1 free month)
* we will need to see evidence of this.
Amount Due : AUD
   
Username :
Password : atleast 5 characters
re-type password:
3) Special information
Is there any special requests or information you feel we should know regarding this application? (please enter it below)
Where did you hear about CBServers?
Please enter a referral code here (if you have one)


 

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