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Application for Services – Web Package / Domain Registration

|Customer |

|Company Name: |      |Date: |      |

|Contact Name: |      |Account No.: |      |

|Home Phone: |(     )      |Agent: |      |

|Email Address: |      |CSR Completed: | |

|Admin Name: |      |Admin Phone: |(     )      -      |Admin Email: |     @      |

|Tech Name: |      |Tech Phone: |(     )      -      |Tech Email: |     @      |

|Domain Name: |      | New Domain | Transfer Domain | |

|Privacy: Prevents customer information from displaying on Whois, this is currently not available for Corporations using .ca (please contact CIRA for more |

|information). |

|For .ca or .on.ca Domains, please define the Legal Type: | |

|Briefly Describe the Organization that the Domain is Being Registered For:       |

|Web Packages |

|Hosting |Disk |Anti-Spam |Email |Monthly |1 Year |2 Years |

|Package |Space |Anti-Virus |Accounts | | | |

|Bronze |1 GB |Free |200 | $9.95 | $107.40 | $202.80 |

|Silver |2 GB |Free |500 | $14.95 | $161.40 | $304.80 |

|Gold |4 GB |Free |1000 | $19.95 | $215.40 | $406.80 |

|Platinum |6 GB |Free |1500 | 29.95 | $323.40 | $610.80 |

|SSL – Secure Socket Layer | $99.00 | $198.00 |

|NOTES: All packages include one Domain Registration of .com, .net, .org, .biz or .info. Additional $19.92 one time yearly charge applies to registration of .ca |

|or .on.ca. Additional $59.95 one time annual charge applies to registration of a .tv domain. A minimum of six months of Web Hosting is Required for the one |

|Domain Registration to be included in monthly hosting rate. |

|Custom Web Design Quotes | $      |

|E-Commerce Solutions Available Upon Request | $      |

|Domain Parking | $49.95 per Year |

|Email Spam Filtering | .95¢ per Account (minimum of 10 accounts) |Number of Accounts:       |

|Domain |.com, .net, .org, .biz, .info |Domain Name:       | $30.00 per year |

|Registration Only | | | |

| |.tv |Domain Name:       | $69.95 per year |

| |.ca, .on.ca |Domain Name:       | $45.00 per year |

|Customer Name: |Signature: |Date: |

|INTER|OpenSRS | New | Transfer | No Transfer |User Name:       |Password:       |

|NAL | | | | | | |

|USE: | | | | | | |

| |DNS | Add – if required | Update – if required |Hosting Server: |

| |Control Panel | Add Client | Add Domain |User Name:       |Password:       |

| |iVue | Add New | Update Existing |Customer ID:       |

| |Notes:       |

| |CSR Name |Signature: |Date: |

-----------------------

Nexicom

5 King Street E., Millbrook ON L0A 1G0

Phone: 705-775-6394 or 1-888-NEXICOM

Fax: 705-932-2329 or 1-877-634-8148



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