Account Set Up Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=200 BGCOLOR="#333366" TEXT="#080000" background="03cc8c00dkcfsz.gif"> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <FONT SIZE="5" COLOR="#666633" FACE="Arial" ><B>ArtBanshee's WebHosting</B></FONT>     |     <A HREF="index.htm" TARGET="_top" TITLE="ArtBanshees WebHosting"><U>home</U></A></div> <div> <A HREF="id15.htm" TARGET="_top" TITLE="Our System"><U>Our System</U></A>   |   <A HREF="id3.htm" TARGET="_top" TITLE="Web Hosting Packages"><U>Web Hosting Packages</U></A>   |   <A HREF="id4.htm" TARGET="_top" TITLE="Acceptable Use Policy"><U>Acceptable Use Policy</U></A>   |   <B>Account Set Up Form</B>   |   <A HREF="id16.htm" TARGET="_top" TITLE="Order"><U>Order</U></A>   |   <A HREF="id18.htm" TARGET="_top" TITLE="ECommerce Links"><U>ECommerce Links</U></A>   |   <A HREF="id6.htm" TARGET="_top" TITLE="Contact Us"><U>Contact Us</U></A></div> <div> <I>Account Set Up Form</I></div> <bR> <div> This form must be completed and payment received in order to set up your account.</div> <bR> <bR> <div>  <form action="http://formmail.trellix.com/servlets/TlxMailer" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="Contact's Full Name,Contact Email,Company,Address1,Address2,City, State, Zip,Phone,Fax,Domain Name,Change NameServer Info?,Registrar,User Name,Password,Additional Comments/Instructions"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Payment must be made before we set up your account. You will be notified within 24 hours (upon receipt ofpayment) by email when your account is set up. If you do not get a response, please email webhost@artbanshee.com. Thank you for your order."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="URGENT - New Account Set Up"><input type="hidden" name="tlx_EmailTo" value="webhost@artbanshee.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">Contact's Full Name:<br> <input type="text" name="Contact's Full Name" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Contact Email:<br> <input type="text" name="Contact Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Company:<br> <input type="text" name="Company" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 1:<br> <input type="text" name="Address1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 2:<br> <input type="text" name="Address2" size="30" maxlength="100"></td> </tr> <tr> <td align="left">City, State, Zip:<br> <input type="text" name="City, State, Zip" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Fax Number:<br> <input type="text" name="Fax" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Domain Name (include .com, .org, etc.):<br> <input type="text" name="Domain Name" size="30" maxlength="100"></td> </tr> <tr> <td> <input type="checkbox" name="Change NameServer Info?" value="yes"> Check this box and complete the remaining information if you want us to handle the nameserver information for you</td> </tr> <tr> <td align="left">What company did you register the domain name with?:<br> <input type="text" name="Registrar" size="30" maxlength="100"></td> </tr> <tr> <td align="left">User Name/Account Number:<br> <input type="text" name="User Name" size="10" maxlength="10"></td> </tr> <tr> <td align="left">Password:<br> <textarea name="Password" rows="5" cols="30"></textarea></td> </tr> <tr> <td align="left">Additional Comments/Instructions:<br> <input type="text" name="Additional Comments/Instructions" size="50" maxlength="200"></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </div> </td> </tr></table></body>