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Virtual Hosting / Site Design Signup Form

Once we receive your information, we will bill you through PayPal.
All major credit card, debit, and online-check payments are accepted.
Need a secure Paypal account?  Click here!  It's FREE!

Don't want to pay online?  Contact us to make special payment arrangements.
Your Company Name:
Your First Name: *
Your Last Name: *
E-Mail Address: *
Address1: *
City: *
State: *                       Zip Code: *      
Country: *
Telephone: *
Domain Name: *
         i.e "" (your primary account, if you're using multiple domains)
    Is this domain already registered with Internic?    Yes    No
         If no, do you want us to register this domain for you?  
Yes    No
                 (Domain registration is $12.00 per domain name, and must be renewed annually.  This additional cost will be added to your total bill.
                 Please note - the domain name you desire may not be available.  We will contact you with alternative domain name options if your
                 choice has already been selected by someone else.)
Requested Password for your Domain:   
          (6 to 15 Characters in length. Passwords are case sensitive)
Hosting Plan: *
Design Package: *

      Package Desired:
(Please select your    
favorite pattern here.)   

Black:           Blue:  
Brown: Gold: 
Green: Orange: 
Red: Silver:

Feature Plus Add-on's

Can be added at any time
Extra Disk Space in MB's? (400MB increments)
Extra Email Boxes? (Each domain already has its own)
Extra FTP Users? (Each domain already has its own)
MySQL Database(s)? (How many?)
SSL (our Key) How many domains
Extra Sub Domain(s)? (
 Other Comments: 
I agree to the Acceptable Use Policy.

We will make every effort to process your request immediately. However, we are only human, and have to sleep sometime. ;-) Please allow 24 hours before receiving your access and configuration information.

All hosting fee's are due on the 1st of each month for that month.
Late payments (after the 5th) will be accessed a 10% late charge.
Customers that are overdue may find their accounts suspended.

Graphics, Etc...
118 Barnacle Place Rockledge, FL 32955
Phone: 321-213-1022 FAX: 800-887-4198

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Please send mail to with questions or comments about this web site.
Copyright © 1989 Graphics, Etc... Website Design
Last modified:  02/23/2013