TASAM ORDER FORM

Please print and fill out the form below and snail mail to :


	ServerRack.Net
	13504 Highland Drive
	Boston, VA 22713

NOTE: Please make your checks out to ServerRack.Net, Inc.

      ** Payments MUST be made in US Dollars **
      **  $25.00 FEE ON ALL RETURNED CHECKS  **
      ** Please Print Account Name ON Checks **

Username (16 character limit) : ____________________

Your Current Email Address : _____________________

Voice Phone Number (optional) : __________________

Were you refered by anyone?   : __________________

Desired Hostname (whatever.tasam.com) (for Vhosting only) : ___________________

If you are ordering our domain hosting, What domain?      : ___________________

Services 
(please check one, see the services page for account details.)

___ Standard Shell ($10.00)              ___ Shell with Vhost ($15.00)

___ Shell with Domain ($20.00)           ___ Professional Web Hosting (* $75.00 Total)

* Includes one time setup fee of $50.00. There is no setup charge for shell accounts.
* Entails 25.00 a month recurring fee.

Need something special? List it here :  ___________________________________________

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