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Dedicated Servers >> Submit New Order >

Submit New Order:

All fields are required, please.

Section 1: Personal Contact Information

First Name:

Last Name:

Street Address:

City & State:

Zip Code:

Country:

Home Phone:

Contact Email Address:

Section 2: Web Site Configuration:

Admin User Name:

Password (3 - 8 characters):

Section 3: Domain Name Information:

Don't forget the extension:
.com, net, org, or other!

Your Domain Name:

	My domain is a new domain that has not been registered, please register it for me.
	I already have a domain name, please transfer it for me.
	I will register or transfer my own domain.

DNS SERVER INFORMATION

PRIMARY

COBRA.SIMPLECOM.NET

208.62.162.2

SECONDARY

NS2.SIMPLECOM.NET

216.77.84.8

SECONDARY

NS1.SIMPLECOM.NET

208.62.162.3

Final Section: Payment Information:

Credit Card #

Expiration Date:

Exact Name on Card:

Any additional comments?

PLEASE CHECK ALL FIELDS BEFORE YOU SUBMIT!

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Fax: 205-758-4407

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