Genext | Sign-Up : Web Hosting

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Profile Information:

First Name:

Last Name:

Company:

Address:

City:

State:

Zip:

Phone:

Alternate Phone:

Fax:

Email:

Domain Name:

Current Domain Name:
Where is it currently hosted:
What is there phone number:
Are you authorized to make this tranfer?

Account Information:
Please select your administrative username:
1st Choice:	@yourdomain.com
2nd Choice:	@yourdomain.com
Choose Your Password:
1st Choice:
2nd Choice:
(Password must be 5 to 8 characters: Alpha-Numeric only)

Webhosting package comes with 100Mb of Web Space and 5 email addresses.
Billing Information:
Billing Period:
Billing Options:
Other Email:
** Autopay Requires Authorization Form
How many Emails:
*up to 5 included, $2 each past 5
System Information:
Select the hosting features you require:
	Front Page Extensions CGI Scripting Active Server Pages (ASP) Server Side Includes (SSI)
General Comments:

How Did You Hear About Us?


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