RESELLER ACCOUNT ACTIVATION REQUEST FORM

Virtual Hosting Services
Nova Products 350 Ward Av #106 Honolulu HI 96814

RESELLERS ONLY
SECURE ONLINE PAYMENTS
NOTE: ALL PRICES IN US $

RESELLERS NAME:

RESELLERS ID #:
RESELLERS EMAIL:

YOUR CLIENTS ACCOUNT INFORMATION:

Name:
Organization:
Address:
City, state, Zip:
Country:
Phone Number:
Email Address:

ACCOUNT TYPE

HOSTING PLANS:
LINUX Hosting Plan $89.10 1 year Contract
WINDOWS Hosting Plan $89.10 1 year Contract

FTP USER
FRONT PAGE USER

Select FTP user unless you are using MS FrontPage to design your web pages

DOMAIN REGISTRATION INFORMATION
If you are not sure whether your domain name is still available you may search internic's records with WHOIS. Otherwise PROCEED!

Please Host the Following Domain name:
Specify .com, .net, or .org ,biz, ,info

This is a New Registration
This is currently Registered
Comments?:

Payment Method

Credit Card

******Do NOT send Checks or Money Orders to our Mailing Address. We do not accept this payment method******

CREDIT CARD INFORMATION
Note all information is Required

Credit Card Type:

Credit Card Number:

Expiration Date:

Name of Cardholder:

Cardholders Address:

Cardholders City, State

Cardholders Zip Code:

Total to Charge:

Please read through the Service Agreement carefully.
I have read the Service Agreement and agree to the terms and conditions: please sign me up:

Credit Card Type:
Credit Card Number:
Expiration Date:
Name of Cardholder:
Cardholders Address:
Cardholders City, State
Cardholders Zip Code:
Total to Charge: