EmailHosting Request – Pixelgate Networks

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Selected Email Hosting Plan

Please provide us with the Domain Name you will be Hosting

Domain Name

Billing Information

Company

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Fax Phone

Email Address

Referral Information

Referred By

Referrer's Email

Setup Information

Initial User ID

Note: 6-16 characters. Use lowercase letter and numbers

Initial Password

Note: 6-16 characters. It is case sensitive, needs to mix case, numbers and special characters and may be changed later

Special Instructions

Please review the Terms and Conditions for the Pixelgate service. BY PRESSING “I ACCEPT” I agree that I have reviewed and accept the Terms and Conditions and understand that my use of the service will be subject to the Terms and Conditions. Your Credit Card will be charged for the 1st months service plus any setup charges that apply.