Please provide the following contact information about yourself:

CUSTOMER INFORMATION
First Name
Last Name
Title
Organization
Phone
FAX
E-mail
Web Address

 

BILLING INFORMATION
Purchase Order #
Address
City
State	ZIP Code

Please provide the following ordering information:

ORDER SELECTIONS
Select	Domain Names	Price/Yr	List desired domain names
	Domain Name 1	$10.00
	Domain Name 2	$10.00
	Domain Name 3	$10.00
Select	E-Mail Services		Choose Level of Service
	Wyzmail Service	$15.00	your_name@wyzmail.com
	Domain E-mail	$25.00	your_name@your_domain.com
	MS Exchange E-mail	$120.00	your_name@your_domain.com
			List desired e-mail addresses
	E-Mail Account 1
	E-Mail Account 2
	E-Mail Account 3
	E-Mail Account 4
	E-Mail Account 5
Select	Web Hosting Services
	WyzHost Basic	$25.00	Virtual Domain(www.yourname.wyzhost.com), Web Site
	WyzGuys.net Student Site	$50.00	1 Domain Name, 1 Web Site, 5 E-mail Accounts
	WyzHost Web ID	$60.00	1 Domain Name, 1 Web Site, 5 E-mail Accounts
	WyzHost Bronze	$75.00	2 Domain Names, 2 Web Sites, 10 E-mail Accounts
	WyzHost Silver	$90.00	3 Domain Names, 3 Web Sites, 15 E-mail Accounts
	WyzHost Gold	$150.00	5 Domain Names, 5 Web Sites, 25 E-mail Accounts
	WyzHost Platinum	$250.00	10 Domain Names, 10 Web Sites, 50 E-mail Accounts

Please include additional comments or requests below.  If you are purchasing more than 3 domain names or 5 e-mail accounts, please list them below.  If you want us to research the availability of additional domain names, please list them below.