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Koi Media Sign Up

About You:
Company:	Email:
First Name:		Please insure that you can receive mail at this account. A confirmation message will be sent to this account. No website setup will be started until you confirmation the website setup request.
Last Name:
Address:	Phone:
City:		We will also use this number to confirm your account and information. Please include your area code.
State / Prov:
Post Code or ZIP:	Fax:
Country:

Account Details: (Please retain)
Password:		Confirm password:
Passwords are a maximum of 12 characters.

Domain Details:

Domain name or names:

Do you require domain registration?

If you are submitting for a domain registration, please be sure that the domain name has not already been registered to someone else. You can check domain names at http://www.opensrs.com.

Hosting Plan Details:

What server type do you require?

Website Add Ons:
	List Server (Microsoft Server) One time $50 - (More Info)	Credit Card Transaction Services Price Varies (More Info)
	FrontPage 2002 (Microsoft Server) Free	FrontPage 2000 (Microsoft or Linux) Free
	Advanced Stats $50 Per year (More Info)	Live Chat $50 Per year (More Info)
	Domain Parking $5 per year (More Info)	Directory Security (Microsoft Server) Onetime $100 (More Info)
	Website development Price Varies - (More Info)	Additional requirements - please contact me.
	Microsoft SQL Server $50 Per year	MY SQL Server $50 Per year
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