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Domain Name & Login Information

Domain Name	:	(Not required)
		If you need to REGISTER a domain name, please CLICK HERE
Username	:	* (6-15 Characters)
Password:	:	*
Confirm Password	:	*

Contact Information

First Name	:	*
Last Name	:	*
Company	:	(Not required)
Address	:	*
City	:	*
Country	:
State / Province	:
		If state is not applicable choose "Other ... / Not Applicable" from the choices
Zip / Postal Code	:	* If no zip code is applicable, Enter "NA"
Phone Number	:	*
E-mail	:	*
Confirm E-mail	:	*
Your welcome email and login information will be sent to the above email address. Make sure it is valid and that you have access to it.

General Information

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How did you hear about the EICRA HOST service?

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What will you use your EICRA account for?

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* I AGREE to the EICRA HOST Terms of Services. Spam, IRC & Warez is NOT tolerated

Billing Cycle

Please Select Billing Cycle :
	Monthly: $6.95/month
	Quarterly: $6.50 (Prepaid $19.50)
	Semi-Annually: $5.95 (Prepaid $35.70)
	Annually: $5.50 (Prepaid $66.00)

Additional Account Information

Password For Your Account	:	*
How did you find out about us?	:	(Not required)
Did you speak to a representative, if so, who?	:	(Not required)
Are you going to use Microsoft FrontPage	:	*

Domain Information

Feedback	:	If transferring from another web host, please give us some feedback on why your moving:

Comments	:	Description of Web Site (REQUIRED): (You may also use this area to supply any additional notes regarding your order)

Terms & Conditions

Agerrment

I have read and I understand the EICRA HOSTING Policies, Terms & Agreements. I agree to abide fully by all conditions, rules and regulations described therein.

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