| DynIP US & International Registration Form
Registered DynIP Customer
| First Name |
|
Last Name |
|
| Company |
|
| Address |
|
| |
|
| City |
|
State/Prov. |
|
| Zip/Postal Code |
|
Country |
|
| Telephone |
|
| E-mail address |
|
Registration Key
(from About Tab) |
|
Service Options
| Quantity (yrs.) |
Service |
Price (US $ /year) |
Total |
| |
DynIP Basic |
$39.95 |
|
| |
DynIP Pro
Domain Name: |
$69.95 |
|
| |
DynIP Enterprise Edition
Domain Name: |
$199.95 |
|
| |
Subtotal |
|
| Plus 13% Tax (GST/HST #898246574RT) |
13% |
|
| Total Enclosed |
|
Payment Method
Credit Card Information
| Card Holder Name |
|
| Card Number |
|
Expiry Date |
|
| Signature |
|
Credit card customers please note that you will be billed in Canadian funds,
and that the exchange rate will appear on your card statement!
| Please mail or fax the completed form to: |
CanWeb Internet Services Ltd.
1086 Modeland Road
Building 1010 - Suite 201
Sarnia, ON, N7S 6L2, CANADA
Fax: +1 (519) 332-6464 |
You will be sent confirmation of your payment by e-mail.
US Customers: Please note that US $0.63 is required for mail to Canada! Thank You!
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