Secure Signup Form

 

Sign Me up For:  (You will be contacted with further instructions after the order.)

 

  Dedicated Server - $650/Mth ($250 One-Time Set-up fee)
  Co-Located Server - $350/Mth ($250 One-Time Set-up fee)
  Web Hosting - $14.95/Mth

 

Customer Information:

Customer Name:
Address:
City: State: Zip:
Country: Telephone:
Fax: E-mail:

Domain Name:

Payment Options:

1) Pay by Credit Card

Name, exactly as it appears on the Card:

Card Type: Card Number:
Expiration Date:

2) Check/Money Order (Fill out this form, print and mail to address below, along with your check or money order. NOTE:  Don't hit the submit button if you choose this option.)  We also take checks by fax.  If you want to pay with a check by fax, simply print this out and fax in the order form, tape your check below this page.

Tristateweb / M&A
2 N Church St
New Lebanon, OH 45345
Phone/Fax (937)242-7150