QuantumHost - Secure Order Form

QuantumHost Secure Order Form

Company or Domain Name:

Your Full Name:

First Name or Nickname:

Your Title:

Department:

Address:

Address2:

City:

State or Province:

Zip or Postal Code:

Country:

Primary Web Site: http://

E-Mail Address:

Source:

Area Code and Phone:

numbers only

Extension:

FAX Number:

numbers only

Please Select the Services you Require

Webhosting and Q-Form Services

Please select the type of Webhosting Service you would like. FrontPage extensions are installed as part of our regular service. Standard Webhosting Services Packages range in price from $14.95 per month to $49.95 per month depending on the services you select. Additional Add-On services are available.

Select the Type of Service:

Type of Access:

FrontPage Access Only FTP Access Only N/A Q-Form Only

FrontPage and FTP are available but may not be combined as accessing a FrontPage site via FTP can be detrimental. Please select the method which suits your needs.

Create Your Password:

6 to 10 characters, Alpha Numeric Only

This password will be used by you to access your account. It must be at between 6 and 10 characters. Please use only Alpha & Numeric values. Note that your password is case sensitive

Website Name: http://www.

use Domain Name Only. DO NOT include www.

This is the Website Name for which QuantumHost is to establish services. If you only require Q-Form Services, please enter NONE in this field. If you require a Domain Name and have not chosen one, you may go here to select and register an available name: Find a Domain Name & Register

Q-Form Services for GoldMine Software

Webhosting Accounts (except the Brochure Account) include Q-Form at no additional charge. Please fill in the information below to use Q-Form to collect data from the Internet and Automatically create Contact Records in GoldMine® Software. Using the Q-Form wizard you may create as many Forms as needed for each unique website. Using a single Q-Form Service on multiple websites is not permitted. Q-Form processing services (without Webhosting Services) are $14.95 per month and include the Q-Form Wizard.

Send my Q-Form Data to
this e-mail Address:

If you are signing up for a Brochure Account, please type BROCHURE in the field above

Website Design

You can create your Website Design yourself, or elect to have QuantumHost design your website for you. If you elect to have QuantumHost design your website, we will contact you regarding particulars and the materials we will need to accomplish your Website Design.

Website Design Services:

Basic Pricing is determined by total number of pages. Pricing Info

Credit Card Payment Information

Payment Plans:

Card Number:

numbers only

We accept Visa, MasterCard, Discover or American Express

Expiration Date:

mmyy format

Name on Credit Card:

Billing Address and Zip:

Additional Information

Referred by:

Notes and Comments:

Please include all additional instructions you have in this area. Be as informative as possible. We will do our best to carry out your instructions as they pertain to the QuantumHost Internet Services you have selected.

click to view the Service Agreement

Submit Your Order Only after you have read and Agree with the Terms and Conditions