A1 DOMAIN NAMERESERVATION & REGISTRATION SERVICES ORDER FORM

A1CO.COM

Section 2: Payment Information
This is for A1's staff use only.

Section 3: Submission Information
This is for gathering the information we will submit on your behalf (this information will be public).

GO BACK TO: A1 Web Page Promotion and Advertising Services home page.

If you experience difficulty using this form please email us for a text version of our registration form or call 1-450-458-1868.

SECTION 1: Personal Information
Go back to the Top

How did you find us?:

Your Name:

Your Email Address:

Domain Name:
( eg: abc.com or abc.net )
.com, .net, .org
http://www.

Your Telephone Number:

Your Fax Number:

Any comments you would like to make to A1:

SECTION 2: Payment Information
Go back to the Top

We must receive your payment before we can process your order.

NOTE: If you do not want to have this information eMailed to us, you can call us in person at our voice number or Fax us your Credit Card number, OR you may fill out this form, print it out and Fax it to us.

Our voice number is: (450) 458-1868, our Fax number is: (450) 458-8224.

Choose from one of the following items:

Method of Payment:

Card Holder's Name:

Credit Card Number:

Credit Card Expiration Date:

Money Orders (in US funds) should be made out to A1 Internet Services and mailed to:

A1 Internet Services
P.O. 1121
Hudson, Quebec
Canada
J0P 1H0

SECTION 3: Domain Registration Information
Go back to the Top

Organization (Or Individual) Domain Name Registered To:

Organization's Name:

Address:

City:

State:

Postal Code:

Country:

THAT'S IT! After submitting, a thank you page will automatically appear - this indicates that we have successfully received your information. Your Domain Name Registration should be completed within 24 hours of receipt of your order, if payment is included. If you do not receive a confirmation letter from us within 48 hours (Monday to Friday) please contact us at 450-458-1868.

Thank you for using our service. Questions and comments can be eMailed to: info@a1co.com

We don't have any small print, so please read the following carefully before pressing the submit button: By submitting your order you acknowledge that you agree to pay A1 Internet Services / Aurora Promotions the sum of $49.00 and to pay InterNIC $70.00 for the first 2 years of registration.

SUBMIT: To clear the form, press this button:

Domain Name: ( eg: abc.com or abc.net ) .com, .net, .org

Organization (Or Individual) Domain Name Registered To:

Organization's Name:

Address:

City:

State:

Postal Code:

Country:

Domain Name:
( eg: abc.com or abc.net )
.com, .net, .org