Service or Product
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Customer Information
First Name
Last Name
Company
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Billing Address
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Zip Code
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Phone
Primary Email
Offsite or backup Email
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Billing Information
Billing Method	Check / Money Order PayPal Credit Card
For check / money orders, simply fill out then print this form and mail or fax. For PayPal orders, please submit this form, then select the PayPal logo at the bottom for payment.
Which Credit Card	Visa American Express MasterCard Discover
Billing Frequency	Monthly Annual
Credit Card Number	e.g., 4123-4567-8910-1234
Expiration Date	1 2 3 4 5 6 7 8 9 10 11 12 / 2001 2002 2003 2004 2005 2006 2007 2008
Name on Credit Card

Referral
How did you find us?
If recommended, please enter the domain name of the referrer:	www. By crediting your referrer, they will get one month's hosting free at LMGraphix Internet Solutions, Inc.

Account & Domain Name Information
Account Type	Standard Professional Developer Commerce
Choose a User Name*:	(maximum 8 characters)
*The user name must start with alpha characters and consist of lower case alpha characters, numeric characters, the minus sign "-" or underline "_".
What is (or will be) your domain name?	www.
Please choose one of the following:
This is a new domain name - please purchase for me.
I already own this domain name.