Request Web Hosting

If you have any questions about this form or having Optimus Media host your web site, please contact us. We would be happy to answer any questions you may have.

How did you hear about us? We're you referred to us by a website or individual? If so, please tell us here.

Creating a New Domain
Moving an Existing Domain
If you are creating a new domain and have not yet secured the name, check here and we will do that for you for only 20.00 per year, per domain name.
Domain Name Ex: http://www.example.com (enter additional names in the same box, separated by a comma.
Your Name
Organization
Address
Address 2
City
State
ZIP
Phone
Fax
Your current email address.
Promo Code (if you have one)
Billing Cycle
FrontPage Extensions? YES NO Frontpage Extensions allow users of FrontPage to publish to their website and use other features. Non-frontpage users should select no, as they add extra space to your site that you will never use.
Domain Access You (or your webmaster) will need a user name and password to access and edit your website
username (8 char. max)
password
retype password
Additional Comments (if any)
I am at least 18 years of age and I understand by submitting this form I agree to all terms and conditions and understand that this constitutes an order for services, not a request for information. Domain registration and setup fees are non-refundable.

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