Secure Order Form

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Secure Order Form
Your Domain Name:
http://www. (Please specify domain ending)

Choose new domain below if you are registering the domain for the first time.
Choose "
Transfer" if you are transferring this domain from another hosting company or registration service.

New domain  Transfer existing domain  I will handle my DNS change

The user name must start with alpha characters and consist of alpha characters, numeric characters, the minus sign "-" or underline "_". Alpha characters must be in lower case. The length of User Name should be no more than 8 characters. For example, John Doe can have the user name 'jdoe'
Choose User Name: This will be your default email address! (
Hosting Plans:
Contract Length:

(Appropriate amount will be discounted)
(2 year plan - we waive the setup fee)

Get a Professional Web Site Developed Quick, Easy and at Less Expense
Utilizing Our Web Master(s) & Our Development Styles

Choose A Desired Development Style I - IV
( Click Here for Examples )

I $250.00 *
(3 Page Site)
II $600.00 *
(5 Page Site)
III $1200.00 *
(7 Page Site)
IV $2000.00 *
(15 Page Site)

How many additional "nav bar" links?

Links as indicated in the "popups" below with the appropriate default amount of links
per style, correspond to "pages" below that. Note: 3 links get 3 pages, 5 links get 5 pages

(links that require extra button creation are $20.00 ea. and need to be specified with a check below)
If you need extra links without buttons, then please indicate this within the comments below.

Extra Button(s)
Extra Button(s)
Extra Button(s)

If you use the popup above to choose extra link(s) , it is assumed you will supply the
URL(s) for the link(s) if you do not choose additional page(s) below, for which there
is no
extra $65.00 charge in this case ("0 Page" indication below).

Please specify the URL(s) in the comments below if this is the case.
Example: the extra link is to email you at the specified email address, or
within your copy (content) you have words linked to specified URL(s)
(another page within your site or an off site link).

How many additional pages?
(Each additional page is $65.00, which is added to the prices above)

* Please see our design & development page to be certain of what you want.

Comments should be ordered for clarity like this:

1-3 word(s) at most for naming of your links (may be buttons if a Style II, III, or IV is chosen).
Specifics of any extra links chosen. (email, and/or put 2-3 lines of content here with links underlined)

Please see our examples for pricing guide lines


After sending this order to us you will be contacted at the email address you list below with
a "Hosting Confirmation" letter, giving you an IP address, a brief explanation of control panel
access, and how to contact us regarding your responsibility for getting us your
content if you ordered development within the hosting order process.

Check this box if you'd like to secure a graphic artist contract for your development needs.
We will contact you regarding this contract through the confirmation letter
and finalize it by contacting you at the phone number(s) you list below.

Contact Information

Required fields marked with *

First Name
Last Name
Street Address City
* *
State/Province Zip Code
*  *
Country Other (if specified) Email
 *  *  *
Phone Work Phone Fax

Please enter an alternate e-mail address below such as a Hotmail address,
so we can reach you if your main email is down.

Alternate E-Mail

Payment Information

Payment Type:
Credit Card  Check
Card Type:
Personal Name on card:
Card Number:
e.g., 4123-4567-8910-1234
Expiration date: /
If paying by check or money order, make payable to "Video Integrations" and also submit this form.
Mail payment to:

Video Integrations
3460 Valley Glenn Lane
Napa, CA 94558

Note: Check/Money Order must be received before account is activated.

How did you hear about us?

If other: (Appreciated)

* By submitting this order, I agree with the terms and conditions outlined in the Acceptable Use Policy.

Send your order for hosting by clicking the button below:

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