Online Registration Form
Contact Information
* - required fields
Your Full Name
* e.g. Fred Nerk
Your Existing
Email Address
* e.g.
fred.nerk@bigpond.com
Your Organisation
e.g.
Nerk & Associates Pty Ltd
Your best Contact
Phone Number
* e.g. 07 3893 0000,
0412 717 850
Your Address
* e.g. 10 Any St
Address cont'd
* e.g. Anytown, QLD,
4178
ABN (req'd for .au names), or
e.g. 69 101 175 517
ACN (req'd for .au names)
e.g. 101 175 517
Domain Name Registration/Transfer
Domain Name for registration/transfer
*
e.g. nerk.com.au
Domain Name for New Registration
or
Transfer from existing Hosting Provider
Period of Registration
1yr
2yrs
3yrs
4yrs
5yrs
10yrs
Legal Owner of Domain Name
* e.g. Nerk &
Associates Pty Ltd.
Services Required:
Domain Parking
(reserves the domain name for future use)
Domain Delegation
(directs domain name requests to another DNS server)
Website Redirection
(directs web traffic to a pre-existing web site)
Web Hosting (set
options below, serves web pages and email to the Internet)
Notes to help registration/transfer
Include any additional information that may
help us with your Registration, e.g. existing provider, registry keys, login information,
DNS & Web server IP addresses,
etc.
Hosting Details
Hosting Package
Hosting1000($15/month)
Hosting2000 ($25/month)
Hosting5000($25/month)
WebOnly1000($10/month)
WebOnly2000($15/month)
WebOnly5000($25/month)
Custom
*
Period of Hosting required
1yr
2yrs
3yrs
4yrs
5yrs
10yrs
*
Billing Period (in advance)
Monthly
Quarterly
Bi-Annually
Annually
*
Extra Hosting Requirements
Secure Server (add
$10/month)
Database Server (add
$10/month)
Anonymous FTP Server (add
$25/month)
GuestBook/Chatroom
Application (add $5/month)
Custom Application Hosting
(please provide details)
Additional Hosting Notes
Include specific details to help us host you better. If
you have special requirements, just
contact us to sort them out.
Email Details
Email Addresses Required
*
e.g. fred,joe ,harry @nerk.com.au
Email Password
* e.g.
fred:s13$,joe:AbC,harry:t34r
Primary Email Address
* e.g. fred .nerk@bigpond.com
(Account and Billing information will be sent to this
address, we advise you use your ordinary ISP email account here.)
Additional Hosting Notes
Include specific email forwarding and aliasing details
to help us host your email better.
Payment Details
Billing Address
* e.g. P.O. Box 1123
Billing Address cont'd
* e.g. Anytown, QLD, 4178
(if different from address given above)
Payment Method
Choose
MasterCard
Visa
BankCard
Direct Deposit (delayed)
Cheque (delayed)
*
Card number
-
-
-
Name of Card Holder
e.g. Mr. F Nerk
Expires
XX
01
02
03
04
05
06
07
08
09
10
11
12
20XX
2006
2007
2008
2009
2010
2011
2012
Total Billing Amount
* e.g. $90.00
Ongoing Billing Amount
* e.g. $45.00
quarterly
If registering new domains or transferring
existing domains, I acknowledge that immediately the
domain name is registered or transferred, I become liable for its associated charges. I acknowledge that Shaw Technologies will now create services
and charge the above Account Holder on an ongoing basis to provide those
services. I also acknowledge that it is my responsibility to cancel those
services in writing should they be no longer required. I acknowledge that I am
responsible for any additional fees resulting from the provision of these
services, including, but not limited to, excess download fees and setup charges.
A full copy of the applicable terms and conditions is available by request. I
acknowledge that my personal information and information about my connection may
be collected for administrative and marketing purposes, and finally, I certify
that all the information given above is true and correct.
*
I have read, understand and agree with the terms and conditions outlined
above. I fully expect to have my account billed for these services and
agree to settle that account.