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Website Order Form
Fields marked * are required.
Customer Information
 Company Name    
 First Name     *
 Last Name     *
 Address Line 1     *
 Address Line 2    
 City     *
 State     *
 Zip/Postal Code     *
 Country     *
 Phone     *
 Fax    
 E-mail Address     *
 Alternate Email    
Domain Information

Please identify the domain name being hosted. We also need to know if the domain is already registered or if it is a new domain. Please indicate the current status of your domain and if you would like us to register the domain on your behalf.
 Domain Name     * (eg: mydomain.com)Register domain name/
check whether your domain name is available?
 Domain Status     *
 If New Registration     *

Note that any domain names registered by Michigandental.com cost at a non-refundable fee of $15.00 . Domain name registrations can only be performed after we have received your initial payment.
Hosting Plan

Please note that hosting plans are quoted on a per month basis, and billed on a quarterly or longer basis. Setup fees also apply to each hosting plan. All prices are quoted in American dollars.
 Hosting Plan     *
Hosting Plan Details

40MB Disk Storage Space
10 Email addresses (POP3)
Full ASP Support
FrontPage® 2000 Support
MS Visual InterDev® Support
MS Access 2000 Database
SQL Server / Oracle Support (optional)
MS Index Server
Shopping Cart System (optional)
Website Usage Reports/Statistics
Unlimited Email Forwarding
Unlimited Email Auto-responders
Daily Website Backups
Battery Backed-up Servers
Unlimited FTP Access
Flash/Shockwave Support
24 x 7 Expert Technical Support
Security Assurance
Payment Information

Our sales department personnel will contact you within 1 bussiness day about the payment information and confirm your order
Customer Feedback

We are interested in your feedback and invite you to use the following area to give us your comments.

 How did you hear about Michigandental.com? 
  

 Other Comments 
  
Customer Agreement

By checking the box below, you are agreeing to our Terms and Conditions.
     I Agree to Terms and Conditions  *
Clicking on Proceed will take you to the Order Confirmation page. From there you can then review the order before sending it to us.
If need be, you can return to this page to make changes.
If you wish to completely clear your order, press the Reset button.

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