NHTC Web Hosting Application

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=85 BGCOLOR="#FFFFFF" TEXT="#080000" bgproperties="fixed" background="18700660egerdp.jpg"> <div> </div> </td> </tr><tr> <td valign="top" width=150 BGCOLOR="#333366" TEXT="#080000" background="03fcac00dkcfsz.png"> <div> <A HREF="index.htm" TARGET="_top" TITLE="New Hope Telephone Company"><U><IMG SRC="15c821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="about_us.htm" TARGET="_top" TITLE="About Us"><U><IMG SRC="151821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="customer_service.htm" TARGET="_top" TITLE="Customer Service"><U><IMG SRC="152821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="products_and_services.htm" TARGET="_top" TITLE="Products and Services"><U><IMG SRC="153821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="telephone.htm" TARGET="_top" TITLE="Telephone"><U><B><IMG SRC="154821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <bR> <bR> <div> <A HREF="internet.htm" TARGET="_top" TITLE="Internet"><U><B><U>Internet</U></B></U></A></div> <div> <A HREF="accelerator.htm" TARGET="_top" TITLE="Accelerator"><U><B><IMG SRC="16b821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="links.htm" TARGET="_top" TITLE="Links"><U><B><IMG SRC="16c821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="internet_support.htm" TARGET="_top" TITLE="Support"><U><B><IMG SRC="168821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="internet_frequently_asked_questions.htm" TARGET="_top" TITLE="Internet Frequently Asked Questions"><U><B><IMG SRC="161821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="web_hosting_service.htm" TARGET="_top" TITLE="Web Hosting"><U><B><IMG SRC="183821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> </td> <td valign="top" height=395 BGCOLOR="#DDDDDD" TEXT="#080000" background="0eac8c83.jpg"> <div> <FONT SIZE="1" COLOR="#0000BF" FACE="Arial" >  </FONT>New Hope Telephone - Web Hosting Application</div> <html> <head> <title>New Hope Telephone - Web Hosting Application</title> </head> <bR> <body BGCOLOR="CFCFCF" TEXT="000000"> <bR> <center><h1>New Hope Telephone - Web Hosting Application</h1></center> Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if your are not using a forms-capable browser) you may email your response to: <A HREF="mailto:questions@newhopetel.com" TARGET="_top" TITLE="mailto:questions@newhopetel.com"><U><I>questions@newhopetel.com</I></U></A> <form method="POST" action="http://internet.citizens.coop/scripts/nbformmail.pl"> <input type=hidden name="recipient" value="!ques*tions#@newhopetel.c*********************************************************om,!cit**izens##@sw##############va.n************************************************et"> <input type=hidden name="subject" value="NHTC Web Hosting Application"> <input type=hidden name="redirect" value="http://www.newhopetel.net/thank_you_for_your_submission.htm"> <bR> <p><PRE>Last Name: <INPUT TYPE="text" NAME="Last_Name" SIZE=35 VALUE=""></PRE> <p><PRE>First Name: <INPUT TYPE="text" NAME="First_Name" SIZE=35 VALUE=""></PRE> <p><PRE>Company: <INPUT TYPE="text" NAME="Company" SIZE=35 VALUE=""></PRE> <p><PRE>Address Line 1: <INPUT TYPE="text" NAME="Address_Line_1" SIZE=35 VALUE=""></PRE> <p><PRE>Address Line 2: <INPUT TYPE="text" NAME="Address_Line_2" SIZE=35 VALUE=""></PRE> <p><PRE>City: <INPUT TYPE="text" NAME="City" SIZE=35 VALUE=""></PRE> <p><PRE>State: <INPUT TYPE="text" NAME="State" SIZE=2 VALUE="VA"></PRE> <p><PRE>Zip Code: <INPUT TYPE="text" NAME="Zip_Code" SIZE=10 VALUE=""></PRE> <p><PRE>Telephone Number: <INPUT TYPE="text" NAME="Telephone_Number" SIZE=12 VALUE=""></PRE> <p><PRE>Email Address: <INPUT TYPE="text" NAME="Email_Address" SIZE=35 VALUE=""></PRE> <p>Are you currently subscribing to an Internet Plan with New Hope? <SELECT NAME="Current_Plan"> <OPTION SELECTED> Yes <OPTION> No </SELECT> <p>If not, which plan would you like to subscribe to: <SELECT NAME="Type_of_Plan"> <OPTION SELECTED> Basic <OPTION> Accelerated </SELECT> <p>Select the type of Web Site service you wish to subscribe to: <SELECT NAME="Type_of_Site"> <OPTION SELECTED> Personal <OPTION> Commercial </SELECT> <p>Select additional storage space requirements: <SELECT NAME="Storage_Space"> <OPTION SELECTED> None <OPTION> 1 MB Plan <OPTION> 5 MB Plan <OPTION> 15 MB Plan <OPTION> 20 MB Plan <OPTION> 30 MB Plan <OPTION> 50 MB Plan <OPTION> 100 MB Plan </SELECT> <p>Please select the Domain Name you would like (Commercial Sites only):<br> <p>www.<INPUT TYPE="text" NAME="Domain_Name" SIZE=35 VALUE=""> <INPUT TYPE="checkbox" NAME="Extension" VALUE=".com" CHECKED>.com <INPUT TYPE="checkbox" NAME="Extension" VALUE=".net">.net <INPUT TYPE="checkbox" NAME="Extension" VALUE=".org">.org <INPUT TYPE="checkbox" NAME="Extension" VALUE=".biz">.biz <INPUT TYPE="checkbox" NAME="Extension" VALUE=".us">.us <INPUT TYPE="checkbox" NAME="Extension" VALUE=".info">.info <i> (Multiple items may be chosen)</i> <p>Do you want New Hope to register this domain name? <SELECT NAME="Register_Domain"> <OPTION SELECTED> No, it's already registered, please host. <OPTION> Yes, register for 1 year. <OPTION> Yes, register for 2 years. <OPTION> Yes, register for 3 years. <OPTION> No, I'll register myself. </SELECT> <p> <p><b><font size=4>Email Accounts</font></b> <p> <div> <TABLE BORDER="0" CELLPADDING="2" CELLSPACING="1" WIDTH="503" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 20 WIDTH="495"><div> <B><u>Dialup</u></B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> Username</div> </tD> <tD VALIGN=TOP WIDTH="246"><div> Password</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Dialup_Account_Username_2" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Dialup_Account_Password_2" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Dialup_Account_Username_3" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Dialup_Account_Password_3" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Dialup_Account_Username_4" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Dialup_Account_Password_4" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Dialup_Account_Username_5" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Dialup_Account_Password_5" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"> </tD> <tD VALIGN=TOP WIDTH="246"> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 20 WIDTH="495"><div> <B><u>Domain</u></B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> Username</div> </tD> <tD VALIGN=TOP WIDTH="246"><div> Password</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Domain_Account_Username_1" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Domain_Account_Password_1" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Domain_Account_Username_2" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Domain_Account_Password_2" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Domain_Account_Username_3" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Domain_Account_Password_3" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"> </tD> <tD VALIGN=TOP WIDTH="246"> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 20 WIDTH="495"><div> <B><u>Additional</u></B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> Username</div> </tD> <tD VALIGN=TOP WIDTH="246"><div> Password</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Additional_Email_Username_1" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Additional_Email_Password_1" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Additional_Email_Username_2" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Additional_Email_Password_2" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Additional_Email_Username_3" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Additional_Email_Password_3" SIZE=35 VALUE=""></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="246"><div> <INPUT TYPE="text" NAME="Additional_Email_Username_4" SIZE=35 VALUE=""></div> </tD> <tD VALIGN=TOP WIDTH="246"><div> <INPUT TYPE="text" NAME="Additional_Email_Password_4" SIZE=35 VALUE=""></div> </tD> </tR> </TABLE></div> <bR> </td> </tr></table></body> <bR> <bR> <p>Are Front Page Server Extensions needed? <SELECT NAME="Frontpage_Extensions"> <OPTION SELECTED> No <OPTION> Yes </SELECT> <p>Notes Instructions:<br><TEXTAREA name="Notes_Instructions" rows=10 cols=63></TEXTAREA><p> <p>Date: <INPUT TYPE="text" NAME="Date" SIZE=35 VALUE=""> <p>Thank you for allowing New Hope Telephone to provide your web hosting needs.<br> <p> <bR> <p><INPUT TYPE="submit" VALUE="Submit"> <INPUT TYPE="reset" VALUE="Reset"> </FORM> <p> <hr> <A HREF="mailto:questions@newhopetel.com" TARGET="_top" TITLE="mailto:questions@newhopetel.com"><U><I>questikons@newhopetel.com</I></U></A><br> <FONT SIZE=-1>©2004 New Hope Telephone, All Rights Reserved<br></FONT> </body> </html> </td> </tr></table></body>