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Web Site Hosting Request Form

GeneralInformation

Last name
First name
Company
Complete address	</td></tr><tr><td rowspan="1" colspan="1"><p>Phone</p></td><td rowspan="1" colspan="1"><input name="tele" type="text" size="18"/></td></tr><tr><td rowspan="1" colspan="1"><p>Fax</p></td><td rowspan="1" colspan="1"><input name="fax" type="text" size="18"/></td></tr></table></td></tr></table><p><strong>Administrative contact</strong></p><table border="0"><tr><td rowspan="3" colspan="1"><img src="/images/pixel.gif" width="1" height="1" hspace="10" alt=""/></td><td rowspan="1" colspan="1"><p>Last name</p></td><td rowspan="1" colspan="1"><input name="adm-nom" type="text" size="25"/></td></tr><tr><td rowspan="1" colspan="1"><p>First name</p></td><td rowspan="1" colspan="1"><input name="adm-prenom" type="text" size="25"/></td></tr><tr><td rowspan="1" colspan="1"><p>E-mail</p></td><td rowspan="1" colspan="1"><input name="adm-email" type="text" size="18"/></td></tr></table><p><strong>Technical contact</strong></p><table border="0"><tr><td rowspan="3" colspan="1"><img src="/images/pixel.gif" width="1" height="1" hspace="10" alt=""/></td><td rowspan="1" colspan="1"><p>Last name</p></td><td rowspan="1" colspan="1"><input name="tech-nom" type="text" size="25"/></td></tr><tr><td rowspan="1" colspan="1"><p>First name</p></td><td rowspan="1" colspan="1"><input name="tech-prenom" type="text" size="25"/></td></tr><tr><td rowspan="1" colspan="1"><p>E-mail</p></td><td rowspan="1" colspan="1"><input name="email" type="text" size="18"/></td></tr></table><p><strong>Services</strong></p><table><tr><td rowspan="6" colspan="1"><img src="/images/pixel.gif" width="1" height="1" hspace="10" alt=""/></td><td colspan="2" rowspan="1"><p>Do you want us to register a domain name<input name="domaine" type="radio" value="oui"/>yes<input name="domaine" type="radio" value="non" checked="checked"/>no</p><dl><dt>Your domain name or desired domain name<tt>(.org, .net, .com, .ca)</tt></dt><dd><table><tr><td rowspan="1" colspan="1"><p>First choice</p></td><td rowspan="1" colspan="1"><input name="1erdomaine" type="text" size="30"/></td></tr><tr><td rowspan="1" colspan="1"><p>Second choice</p></td><td rowspan="1" colspan="1"><input name="2emedomaine" type="text" size="30"/></td></tr></table></dd></dl></td></tr><tr><td rowspan="1" colspan="1"><p>Disk space required</p></td><td rowspan="1" colspan="1"><select name="espacedisque" size="1"><option value="1-100"> 1 - 100 Mo MB </option><option value="100-500"> 100 - 500 Mo MB </option><option value="500+"> 500 Mo MB + </option></select></td></tr><tr><td rowspan="1" colspan="1"><p>Data transfer volume</p></td><td rowspan="1" colspan="1"><select name="transfert" size="1"><option value="0-1"> Moins deLess than 1 Go/moisGB/month </option><option value="1-3"> 1 - 3 Go/moisGB/month </option><option value="3+"> Plus deMore than 3 Go/moisGB/month </option></select></td></tr><tr><td colspan="2" rowspan="1"><p>Access to secure server<input name="servsecu" type="radio" value="oui"/>yes<input name="msoftext" type="radio" value="non" checked="checked"/>no</p></td></tr></table><p>Other services needed</p><textarea name="autreservices" rows="5" cols="50">

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