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Key West CyberWorks
New Customer Account Web Hosting Registration Form

Please fill-in all information...

Fill Out this Form, then You Should
CLICK Your PRINT Menu Button to Make a Copy
of this Info BEFORE submitting the Form!

PLEASE NOTE:
None of the information supplied here will be made public or shared! 
It is strictly for your account and Key West CyberWorks use, ONLY!
Your Domain Name Information:

Your Domain to Set-Up:
 www.yourdomainname.com

Where is it registered:
i.e.  www.register.com,  www.networksolutions.com, Key West CyberWorks...

Username:

Please supply the log on information for your account with the Registrar where the domain is currently registered if you want us to do the Domain Name Server (DNS) transfer,
else you will be responsible for updating DNS.

Password:
Account Holder Information:

Company Name
(if applicable):
Acct Holder Name:
Mailing Address:
City:
State:
Country:
ZIP Code

Telephone Number:


(Enter Your Area code + Number)
Account Credit Card Information:

VisaMastercardAmerican ExpressDiscover
Card Type:

Please Note: No on-line credit card transactions takes place here.  This form only collects the card account information for manual processing later.  This information is sent to us in an encrypted format as information for setting-up your new web hosting account, only.
Credit Card Number:
(Please enter your card without spaces or dashes, eg. 12345647891)
Expiration Date: Month:    Year:  
Verification Number:
 ◄ What is this? Visa, MasterCard, Discover click here
American Express click here
Your Name as Appears on Card:
Email Address:
 (AOL, CompuServe Users Click here...)
        (Your Credit Card Charge Receipt will be sent to this address...)
Card Billing Address 1:
Card Billing Address 2:
(optional)
City:
State:
ZIP Code:
Country:
Telephone:
(area code + number)  (Used Only for Credit Card or Billing Problems)
Account Type Desired:

You wish to pay:

Type of Account Desired:
 

  Please install Front Page Server Extensions on my account.

 

I want monthly account back-up  for $5.95 per site, per month extra.

Comments or Special Instructions:

  I agree to the terms of the Acceptable Use and Payment for Services Policy
(Click here to view the Acceptable Use and Payment for Services Policy Agreement)
(Click here to download a PDF copy of the Acceptable Use and Payment for Services Policy Agreement)

If any further help/information you can contact us at:

Key West CyberWorks
806 Eaton Street
Key West, FL 33040
(305) 295-9613 

support@kwcyberworks.com

CLICK Your PRINT Menu Button to Make a Copy of this Info BEFORE submitting the Form!

       

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