Home

User name:

Password:

Thank you for choosing Dargal Solutions as your web hosting partner. We value you as a customer and will strive to ensure a quality service. Please fill out the form below.

Part I - Organizational / Administrative Contact Information
Organization Name:
Contact Name:
Mailing Address:
City:
Province:
Postal Code:
Day Phone:
Evening Phone:
Email Address:

Part II - Billing Contact Information
Same as Above
Contact Name:
Mailing Address:
City:
Province:
Postal Code:
Day Phone:
Evening Phone:
Email Address:

Part III - Domain Name (website address)

www.
(Available domain types: .CA, .COM, .NET, .ORG, .BIZ)

Check this box if this domain is already registered.

Please register my domain. Use my application to register my domain name as requested above. I understand that I will be billed $50 in addition to the domain registrar fees.

All domains are subject to registrar approval and fees.

For new domains:
• Your website address should be as short as possible.
• No punctuation other than a dash (-) can be used.

Plan Type		Setup Fee	Monthly Charge	Disk Space Allocated	# Mailboxes	Features and Traffic
Part IV - Select a Hosting Plan
	Gold	$25	$29.95	200MB	30	4 GB transfers, MySQL Access
	Silver	$25	$ 19.95	100MB	20	2 GB transfers
	Bronze	$25	$ 9.95	50MB	10	1 GB transfers
	DNS	n/a	$ 10.00	n/a	2	DNS / Virtual mail hosting only
	Extra Email	n/a	$ 2.00 ea.	n/a	Specify:	Additional Email Boxes

Part V - Additional Services Required

Please specify any additional services you require... Provide as much detail as possible.

Webmaster Password Selection
	Choose this option if you require FrontPage extensions	Please choose your passwords
	FrontPage Userid:	webmaster ( cannot change )
	FrontPage Password:
	Choose this option if you use ftp to upload your site
	Userid:
	Password:

Part VI - Select a Payment Method
Bank Account Debit	Bank #
	Branch #
	Account #

Credit Card	Card Type:
	Card Number:
	Expiry Date:

Part VII - User Agreement

I agree to purchase the above noted Internet Services from Dargal Solutions Inc.(DSI) on behalf of itself and on behalf of DSI, I certify that the information provided on this form is true and correct. I authorize DSI to debit my bank account or credit card for expenses incurred as per the account option selected and that my signature constitutes "Signature On File". By Submitting this form, I also agree to be bound by these Terms and Conditions .

You must agree to both of the following in order to sign up for service:

I have read and agree to this User Agreement
I have read and agree to the Terms and Conditions