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This form is for hosting ordering only!
 If you would like a website built and  hosted, please click here for a free quote.

Required Information

Your Name:

Your address:


State you live in:

Your Zip Code:

Business name you want to register your domain name under:

Phone Number:

Fax Number:

Your E-mail Address? Please Double Check It. Need it to get back with you! :-)
(e.g.: you@aol.com)

Do you have a Domain name now?
 Yes or No

If So, What is your Domain name?

Would You Like Us To Transfer the Domain name?
 Yes or No

If you need a Domain name, what name would you like us to register for you?


Do you want to “PARK” this domain, until you are ready for a web site?
 Yes or No

Which size hosting plan would you like to purchase?

Have you read our Acceptable Usage Policies?
 Yes No

Do you have any other comments?

 How did you find us? What Search Words? (Very Important To Us!)

Did you provide a correct E-Mail address above?

To send to Blais Web Creations,
Thanks for your time!

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 Martin Blais
Stanton, CA. 90680

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