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First Name: (required)

Last Name:(required)

Company Name: not required for personal domain

Street Address:(required)

City:(required)

State:(required)(if other than US, please enter ZZ)

Country:

Zip:(required)

Daytime Phone: (include area code) (required)

Evening Phone: (include area code) (required)

Email Address: (required)

Choose a Service Package

Choose Domain Name:
*Important: The InterNIC, a separate domain registration service
charges $70 for domain name registration. They will bill you
directly for their services.

Choose one:
This is a new domain name
This is an existing domain name
I don't want a domain name now

Choose Payment Method: Only Checks and money order taken at the present time.

Terms of Service:
I have read and agree to the terms of service for an account with Burns Web Services. Box must be checked for acceptance of application.

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