Delta-S Enterprises Order Form

Please fill out the following form. Any fields marked with * are required.

Contact Information

Name:*
Company (optional):
Street Address:*
City:*
For US select State, otherwise select Other and enter Province below
State:*
State or Province:
Postal Code or Zip:*
Country:*
Please give: at least one phone number,
Phone (Work):*
Phone (Home):
Fax (optional):
E-Mail Address:**
Please be sure E-Mail Address is correct.

Best Days/Times to Call You (Home/Work) to confer on work to be done.

Select Web Site Package

Economy
Penny Pincher

Web Site Options

Enter additional options you would like: (multiple options allowed - hold down CTL or SHIFT whilst clicking)

Enter any comments, e.g. suggestions for options

Account details

The information below is requested only for those who are familiar with the Web and already have a good idea what they need.
Secure Server:
Domain Type:
Domain Name:
(second choice):
Domain Transfer: (select if domain is already registered)
Disk Quota: megabytes (specify only if greater than default)
Bandwidth Quota: megabytes/day (specify only if greater than default)

Payment Information

How would you like to pay? Choose any one of the following:
Note: All payment must be made in US dollars.

  1. Check.
  2. Credit card:
    • Mastercard.
    • Visa.
    • Debit Card
      If you want to pay by credit/debit card, you may check the box below and enter your account number here, or communicate that information by phone, fax or email. All of those methods have about the same risk.
      • will submit here
        Card Number:
        Expiration Date: / (mm/yy)
      • will submit by fax
      • will submit by phone
      • will submit by e-mail

Miscellany


How did you find this site?
When you have supplied correct information for all required fields (*), please use the Submit button to proceed.



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Page Maintained By <Delta-S Enterprises' WebWeaver>
Created 08/13/96 Last updated 4/8/98
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