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HOSTING REQUEST FORM

Details
Title	Surname		Existing LocalNet Account (if any)

First Name		Initials	Date Service is required(dd/mm/yyyy)

ID/Company Registration Number		Company Name or Private Account

Postal Address		Physical Address

Code		Code

Code	Telephone Number (Business)	Code	Telephone Number (Home)


Code	Fax Number	Cell Phone Number

Services Required: (Tick where required below)
	Domain Name Registration for www..co.za - R300.00 (Once off)
	Domain Name Registration for www..com - R300.00 (Once off)
	Domain Name Transfer for www..com/.co.za - FREE
	E-mail Hosting (at an existing domain): Monthly Subs - R110.00
	LocalNet Lite Hosting (10Mb Webspace, 1 e-mail address): Monthly Subs - R55.00
	LocalNet Budget Hosting (25Mb Webspace, 3 e-mail addresses): Monthly Subs - R80.00
	LocalNet Standard Hosting (50Mb Webspace, 10 e-mail addresses): Monthly Subs - R125.00
	LocalNet Premium Hosting (100Mb Webspace, 25 e-mail addresses): Monthly Subs - R220.00

E-mail Details
Please choose your e-mail addresses (yourname@)
1.		2.
3.		4.
5.		6.
7.		8.
9.		10.

* Required Fields
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