midPhase Services, Inc.

Please submit form to:
midPhase Services, Inc.
Accounts Receivable
223 W. Jackson Blvd #1014
Chicago, IL 60606 USA

FORM
MPMOF/03

Please include check or money order with this form.

Basic Contact Information
Full Name:
Address #1:
Address #2:
City:
State:
Zip:
Country:
Phone #:
E-mail Addr.:
Web Hosting Account Plan
	Linux Mega-PHASE Charges Breakdown: $95.40/year TOTAL Please Enclose $95.40
	Linux Pro-PHASE Charges Breakdown: $143.40/year TOTAL Please Enclose $143.40
	Windows Basic Charges Breakdown: $119.40/year TOTAL Please Enclose $119.40
	Windows Pro Charges Breakdown: $179.40/year TOTAL Please Enclose $179.40
If you are ordering a DEDICATED SERVER or VIRTUAL PRIVATE SERVER we need to talk to you first. Please call us at 1-866-MIDPHASE and we can explain the fast and easy process. You won't need this form.
Hosting Account Information
Domain Name:	WWW. .
	This is a new domain. Please register it for me. (No charge)
	I already own this domain. Please transfer it for me. (No charge)
	I already own this domain. I will change the DNS settings to midPhase's DNS servers. Please do not transfer this domain. (No charge)
Signature and Date
By signing and submitting this form, you agree to adhere and follow the provisions and clauses found in the midPhase Services, Inc. Terms of Service Contract and Acceptable Use Policy found at this URL: http://www.midphase.com/html_files/terms_of_service.php Please make payment to midPhase Services, Inc.
Signature:
Print Name:
Date: