Customer Sign-up Form

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123 Hosting Web Services
1303 N State Rd 7 # B4 - Margate- FL 33063
Phone 954-917-8781
Fax 954-917-8780

* First Name:
* Last Name:
Company Name:

Address 1:
Address 2:
City:
State:
Zip:

* Phone Number:
Fax Number:

* Main Email Address:
Backup Email Address:

Pay by Check:	* Account will not be activated until we receive payment!
OR
Pay by Credit Card:	* Must be for Address & Zip code from above

Credit Card Type:
Credit Card Number:
Expiration Date:


* New Customer Password:
ReType Customer Password:

Any Special Requests: