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Domain Name Registration Form

   
Your email address:


 Your Full Name:
Domain Name Registering:

Number of years:
NOTE: Please fill out a registration form for each domain you wish to register. If all information is the same for each domain you wish to register, you may list the additional domain names in the comment area below. Thanks!
Registrant Contact Information:

Organization Name:

Registrant Contact Name:

Street Address:

City/State:
  

Zip/Country:
  

Phone


Email Address



Administrative Contact Information:     Same as Registrant: YES NO

Organization Name:

Administrative Contact Name:

Street Address:

City/State:
  

Zip/Country:
  

Phone


Email Address



*Important!* Please choose one of the following options:

I will be:
Hosting my domain immediately - $25/mo
Pointing my domain to this domain name:
with a page - $10/mo
Pointing my domain to this domain name:
directly, no page - $5/mo
Park my domain for now - $60/year

Additional Comments


Other: (method of payment)
You will need to provide us with a check or credit card information before your domain will be registered. Please note that if you choose to mail in a check, your domain will not be registered until we have received it. This will delay the registering of your domain and there is the possibility of losing it to someone else in the interim. MVA.NET can not be held responsible for domains lost in this manner.



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