Welcome to the GayRealms sign up page for Domain Registrations
and Web Site Hosting.

Please fill out the form below.  
You must complete all relevant fields of the form. 

You should make certain that the domain name you want us to register
is available by using the WHOIS function on our Technical Support page.


 New Domain Registration
 Move Existing Domain


 

 Domain Name ( .com .net or .org)
 InterNIC Handle (If assigned)


 Personal Domain
 Client Domain


 
Your Contact Information:

What "Contact Roles" should be assigned to you? Choices are "Administrative Contact" and "Billing Contact". The Billing Contact should be the client. The "Technical Contact" is always GayRealms.


 Administrative Contact
 Billing Contact

 Administrative and Billing Contact

 None - Assign to Client



 
 Company Name (if any)
 Your Full Name
 Street Address 
 Apt. No./Address Line Two: 
 City:    
 State: 
 ZIP or other postal code:
 Phone:  
 Fax Number: 
 Date of Birth: 

Client Contact Information: (Skip this section if you are the site owner.)

 Company Name (if any)
 Your Full Name
 Street Address 
 Apt. No./Address Line Two: 
 City:    
 State: 
 ZIP or other postal code:
 Phone Number:  
 Fax Number:  




Type of Web Site:  

Choose One
Personal Web Space with Domain Name
Basic Business Web Site 10 Megs.
Business Web Site w/25 Megs.
Business Web Site w/50 Megs.
Business Web Site w/100 Megs.
Business Web Site w/200 Megs.
Business Web Site w/500 Megs.
Business Web Site w/1 GIG


Server Type Required  

 Linux w/Apache

 Windows NT/ IIS 4.0

 WIN NT with Front Page Extensions





Payment Information:  
Business Web Site Prepayment Term:

 3 Months (Minimum)

 6 Months (10% Discount)

 1 Year (20% Discount)





Total Payment:

You should have already reviewed the rate page and decided upon the
term you want to prepay. Pick the payment method below. If you will be
mailing payment skip the credit card section that follows.


 Printed Invoice Required

 No Invoice

 Printed Invoice Required for All Parties





How Will You Pay?  

How would you like to pay? (please check one) If paying by other means,
skip to the check/m.o. section.

 VISA
 MASTERCARD
 AMERICAN EXPRESS
 OPTIMA


        
Credit Card Number:   
(eg. 4111-1111-1111-1111)

You may also call our Toll Free 800 Number (Office: 1-800-328-7210)
and provide your credit card number there. 

See further instructions after you submit this form. All other information
on this form must be submitted.  You may also complete the form and
fax it or print it out for mailing, then  press the Cancel button to clear the form so nothing will be sent over the Internet.


Full Name on Card:
(e.g. John Smith)

Card Expiration Date:  
(e.g. 0899)

Will you be paying by check or money order?
 Personal Check (by U.S. Mail)
 Company Check (by U.S. Mail)
 Money Order (by U.S. Mail)

If paying by personal check, please complete the following section.  

Enter Bank Name:
Bank Telephone Number:
Enter Bank Routing Number from bottom of your check.
Enter Bank Account Number:
Enter the Number of the Check You Will Issue for the First  Payment:


Email & FTP Information: 

If you currently have Internet Access, please provide your email address:

Enter Email Address:  
(mandatory)
(Example: name@domain.com )

Verify Email Address:  
(Required)
If you do not enter your email address correctly we can not send your User ID.


When Do You Want to Have Your Domain Set Up?  

USER NAME:

What User Name Do You Want to Use for Email.  
This is the name the world will know you by.


Second Choice, if first choice is not available. 
What Alternative User Name Do You Want to Use for Email.  

PASSWORD:

What Password Do You Want to Use for Your Account?
A combination of letters and numbers is most secure. Passwords are
CASE Sensitive. Use letters/numbers only. No special characters. Up to 8 letters and/or numbers.


Enter the Password for Confirmation

Comments? Additional Needs?




  

For more information on GayRealms Web Hosting , send all your questions or comments to: Info@gayrealms.com We look forward to hearing from you!

Copyright © 2000 GayRealms Web Hosting, a Division of GLINN Publishing Corporation. All rights reserved.