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Web Hosting Signup Form

Just fill out this simple form SureWest will register your new domain name and, if needed, create a virtual hosting account. This information will be used for billing purposes, as well as allowing you to remotely administer certain features of your services.

Fields with * are required.

Account Owner:
* First name:
 John
* Last name:
 Doe
Title:
 Webmaster
Organization:
 ACME Industries
* Address:
 123 Industrial Ln.
Address 2:
 Suite 456
* City:
 Roseville
* State:
 California
* Zip code:
 95678
* Phone number:
- -  916-555-5000
Fax Number:
- -  916-555-5001
* E-mail:
 jdoe@surewest.net
* Confirm E-mail:

Registration Section:

We can host any top level domain (i.e. .biz, .us, .cc, etc.).
However, we can only register .com, .net, and .org.
* Domain Name:    acme.com
This is a new domain (currently unregistered). Register this name for: year(s)
The domain is already registered. I would like to transfer/renew the domain registration through SureWest.
No domain registration required. I have already registered this domain, and would like to set up Web Hosting and or DNS services with SureWest.

Hosting Section:
I would like to set up Web Hosting services with SureWest.

Please choose a Virtual Hosting Package:
 VH1 for $19.95 per month
 VH2 for $39.95 per month
 VH3 for $99.95 per month
Transfer an existing hosting account from current hosting provider.

Please choose a Virtual Hosting Package:
 VH1 for $19.95 per month
 VH2 for $39.95 per month
 VH3 for $99.95 per month
I do not wish to set up Web Hosting services at this time. Please set up registration service only - $15/year.
I have already set up Web Hosting and Registration services for my domain. I would like SureWest to provide DNS services only - $5/month.

Please set up the following DNS records:
(Web, ftp, and www will be set up by default)

Click here to add additional DNS entries.

 

Examples

Host

Type

Answer

  

mydomain.com

A

xxx.xxx.xxx.xxx

mydomain.com

MX

mail.mydomain.com

mail.mydomain.com

A

xxx.xxx.xxx.xxx

mywebsite.mydomain.com

CNAME

mydomain.com

Billing information:
Bill me monthly on my SureWest bill. Please enter billing number or account number.
  Billing Number:  - -  916-555-5000 
 

   -- OR --

  Account Number:
I want to use my credit card.   Please call me for credit card billing information.

To expedite your response, please provide the following:

Account Password:

Please note that all information is securely transferred.