365 N Water Street
P O Box 159
Fort Jennings OH 45844
Phone: 1-800-899-3447
Fax: 419-286-5345
Request for Domain Registration/Hosting
Please print and return completed form to North West Net, Inc.

Domain Account Holder

Your Email Address: ___________________________________________________________________

Your Name ___________________________________________________________________________

Company Name _______________________________________________________________________

Street Address  _______________________________________________________________________

City ______________________________________State _________________ Zip__________________

Telephone Number  ____________________________ Fax Number  ____________________________

Select Three Choices for Your Domain Name Domain names can contain numbers, lowercase letters, and the hyphen. Special characters such as a space or punctuation can not be used.

NOTE: Before you proceed, please remember that registering a domain name is a process that secures a name only. It does not include storage space for hosting of your pages under the domain name. Example: nabisco.com

1. ___________________________ 2. ___________________________ 3. ____________________________

Payment for Domain Name Registration bright.net requires a $50.00 payment for the registration of a domain name.  This payment reserves the domain name for the first 2 years.  You will be billed by bright.net at a rate of $25.00 per year for every year thereafter.  Domain name fees are subject to change at anytime.

Select a Hosting Package

• ___ Standard Package $9.95 - 200 Mb of space.
• ___ Deluxe Package $24.95 - 300 Mb of space.
• ___ Premium Package $49.95 - 400 Mb of space.
• ___ Platinum Package $79.95 - 500Mb of space.
• ___ None, I am hosting my pages elsewhere or I am merely securing the name at this time.  

Payment of bright.net Web Hosting and Setup Charges  bright.net will invoice you for a $50.00 setup charge and your web hosting package.  Please select a payment option:

•         Add the $50 setup, $50 Domain Registration, and monthly web hosting package to my monthly bright.net billing
•        I wish to be invoiced for the $50.00 setup, $50 Domain Registration, and one year (12 months) of web hosting
•        I wish to pay for the $50.00 setup, $50 Domain Registration, and one year (12 months) of web hosting by credit card

By signing this form, I authorize North West Net, Inc bright.net to register a domain name for my organization and set up hosting for storage of my pages if so desired. I understand North West Net, Inc bright.net makes no claims expressed or implied that they can register any given domain name and that all domain names are subject to availability.

Signature _______________________________________________ Date ________________

) 2005 - 20010 North West Net, Inc.