Planetmind Domain Hosting Sign-up Form

Use this SECURE form to Set up a new account.

All yellow fields are required.

Domain Name Desired: (Please make sure it's not taken here.)
If you've already registered this domain yourself, check here:
REGISTRATION INFO
Registrant Name:
Registrant Company:
Address Line 1:
Address Line 2:
City: State: Zip:
Email:
Phone:
BILLING INFO (if different)
Bill to Name:
Bill to Address Line 1:
Bill to Address Line 2:
City: State: Zip:
Email:
Phone:
Hosting Plan Desired: Bronze ($4.99/mo, $59.88/yr)
Silver ($14.99/mo, $179.88/yr)
Gold ($19.99/mo, $239.88/yr)
Platinum ($39.99/mo, $479.88/yr)
ACCOUNT INFO
Administrator Full Name: (This will be the name of the person primarily in control of the site)
Administrator Email: (For technical contact)
Administrator Phone: (For technical contact)
Admin account username: (this will be the login used to maintain the site, as well as the main email address. 4-12 characters.)
Admin account password: (please use 4 or more characters, and 1 or more numbers or special characters (!,#, etc)) Password again:
Supplemental Email addresses
(You may have up to 4 additional email addresses per domain. Extras are $2 per month)

USERNAMEPASSWORDCONFIRM PASSWORD

Comments
(Include any special instructions here.)

PAYMENT INFO
Check, Visa and Mastercard are accepted for payment. Please send checks to:

Planetmind Internetworks
PO Box 1244
Nederland, CO 80466

Credit Card Information
(THIS IS A SECURE FORM)
Name on Card:
Card Number:
Exp. Date (mm/yy):

We usually have domains registered within 24 hours; DNS propigation usually takes 48-72 hours before you site is accessible to the world.