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PLATINUM Website Package - SECURE ORDER FORM

Thank you for choosing AeroHOST. Here's how to proceed:
   Please fill out the form and press the 'SEND' button. The information will be transmitted to our sales department via our SECURE SERVER. Entries on the form marked with an *asterisk are required items.
   For further security, we will send you an email message confirming your order. It will contain a temporary site address (with instructions) so that you can set up your website immediately, while the domain name registration or transfer is being processed. If your domain is new, we will process your registration as a courtesy.
   We have tried to make this process as easy as possible. However, if you have difficulty with the form or need to contact us, just send us an email message describing your requirements on our contact email page.
   If you need to review the plan options, please go back to HOSTING PLANS (opens in new window). Please note that if you leave this page before completing the order, you may have to re-enter the information.

*Asterisk denotes required field. We will eventually need this information, but if you are unsure of what to provide, please leave the field blank and send the order through. We'll contact you by email or phone if we need it later.
Payment Plan:
*Billing Plan ($U.S.): Please choose a plan.
Domain Name:
*Domain Name: eg. aerohost.com
*Domain Status: Is this new (not registered yet) or are you moving from another server, or already parked with us?
*Site Description: A short description of the purpose of your site.
Contact Information:
Salutation:  
*First Name: Your first name
*Last Name: Your surname
Title: Optional Business Title
*Contact Email Address: Your local email address
*Primary Phone: Area Code Phone Where can we reach you?
Alternate Phone: Area Code Phone Your work phone?
Fax Number: Area Code Phone Your fax number
Billing Information:
*Organization Name: Person or company to receive billing. Enter 'same' if as above.
*Payment Method: Please indicate your payment method. 
*Billing Email Address: Email address for initial billing notice
*Address 1: Street Address
Address 2: Extra address or P.O. Box
*City/Town/County:  
*State/Province:  
*Country:
Please enter country name if not on list.
*ZIP or Postal Code:  
ENCRYPTED Credit Card Information:
*Name: EXACT Name as it appears on credit card.
*Card Type: Choose credit card type.
*Credit Card Number: Enter number from card.
*Card Security Code (CSC): Enter 3 digit card security code on back of Visa/MC, or 4 digit code on front of Amex.
*Expiry: Select month and year of expiry.
Website Setup:
Note: If you have difficulty with any of these settings, just leave them blank and we will help you with this later.
User Name: Your unique user ID for access to your site.
Site Password: Use letters and numbers if possible.
Email Setup:
Mailbox 1:    
Mailbox 1 Address: @your domain This will be your administrative address for your mail configuration web interface, where you control your email setup. Example: use 'admin'
Mailbox 1 Password: Use letters and numbers if possible.
Mailbox 1 Forwarding: Enter an existing email address for automatic message forwarding eg. your local email address
Preferred Programming Environment: (Optional)
ASP.NET Please indicate if you plan to use ASP.NET 
PHP  Please indicate if you plan to use PHP
SQL Please indicate if you plan to use SQL Server database

That's all - thanks for your patience. Please review and correct before pressing the SEND ORDER button: