Contact Information  
  First Name Last Name  
  Street Address Phone  
    Alt Phone  
  City State  
  Zip Email  
    Account Information  
  Username Password  
  The username that you choose will also be part of your web site address unless you get a personalized domain name.  
    Choose Your Plan  
 
Monthly - $29.95 /month
6 month contract - $26.95 /month
12 month contract - $22.95 /month
       (BEST SAVINGS!)
Setup Cost: $499.00
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    Billing Information  
  Name on Card Type of Card  
  Card Number Expiration Date  
 
I have read and agree to the terms and conditions listed below this form.

When you submit this form your credit card will be billed for the setup fee which includes your first month's hosting. The billing entity for these charges on your statement will be Infogenix, Inc.
 

Terms and Conditions of Service
Please read the following Terms and Conditions completely prior to submitting the form. You must check the box above labeled "I have read and agree to the terms and conditions listed below" to continue with the sign up process.