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Download printable version - Web Hosting Application form

Web Hosting Application Form
Web Hosting Application Form
PO Box 20 Chadstone 3148 Phone: 03 9885 0655

 Contact Information

Company:
Address:
Suburb: Postcode:
Phone: Fax: Mobile:
Email: Licence No:

 Do you already have a registered Domain Name?

If Yes Please Enter Domain Name

 Web Hosting Package

Basic Standard Business Pro Enterprise
Email Accounts 10 100 200 400 1000
Capacity 50 MB 2 GB 10 GB 20 GB 100 GB
FTP Accounts 1 2 5 10 1000
Databases 0 1 5 10 1000
Sub Domains 0 5 60 100 1000
Add-on Domains 0 0 10 20 100
Parked/Stacked Domains 0 0 unlimited unlimited unlimited
Traffic 2 GB 20 GB 50 GB 100 GB 500 GB
PHP (v5.2.17) yes yes yes yes yes
Webalizer Statistics yes yes yes yes yes
SSH Access no no no yes yes
Web Based File Manager yes yes yes yes yes
Cron yes yes yes yes yes
Custom Digital Certificate yes yes yes yes yes
Anonymous FTP yes yes yes yes yes
CGI yes yes yes yes yes
SSL Certificates yes yes yes yes yes
Web Control Panel yes yes yes yes yes
Webmail Access yes yes yes yes yes
Wordpress, Drupal, Joomla capable no no yes yes yes
Cost per month $ 8 $ 15 $ 25 $ 40 $ 200

 Optional iMail Service

 cPanel Mail please
Mailboxes Aliases Add-on Domains Cost per month
-- 1 Up to 5 Free
up to 5 Unlimited Up to 5 $10
up to 10 Unlimited Up to 5 $15
up to 20 Unlimited Up to 5 $20
up to 50 Unlimited Up to 5 $30
up to 100 Unlimited Up to 5 $50
up to 500 Unlimited Up to 5 $200
   Notes:
  • All prices are including GST.

 Credit Card Direct Debit Authorisation

 VISA  MasterCard  American Express  Other
Card Number:
Expiry: /
Card Holder's Name:

 Agreement

I agree that the above details are true and correct. For credit card payment, I understand that my credit card will be debited for all set-up charges and monthly in advance for the access fee. Once connected, I agree to abide by the terms and conditions found at PCM- agreement or available on hardcopy upon request. This form must be signed if submitting by hardcopy. The signatory must be at least 18 years of age.
Please verify by clicking the "I am not a robot box" before processing application
 I Agree

Download printable version - Web Hosting Application form