Internet Domain Order Form
(Back)

Date __________

To: The Web Author

_______________________ . _____          _______________________ . _____

_______________________ . _____          _______________________ . _____

(Unless noted, the following are all required fields and must be filled in.)

My first and last name _____________________________ Title?________________

Company name ____________________________________ ( Repeat your name if none)

Address _______________________________________________   ___________________________

City __________________________ State _________________ Zip______________

Telephone # ____________________________ FAX # ___________________________ (optional)

E-Mail _________________________________ (optional)

I understand that registration is paid in advance for two years.

I agree that after your registration services are completed, you have performed and fees are not refundable. My check will not be deposited until name availability is determined. I further understand that your liability – if any -- resulting from your services in this matter is limited to the amount of the fee paid, and will indemnify and hold The Web Author and Larry Lowenthal harmless if another party contests my ownership of the domain name. In the event of a dispute, the rules published by Network Solutions, Inc., will apply.

If the name(s) listed above is not available,
__Return my check          ___Contact me about alternatives.

For the company named above,

_______________________________

by (signature)                                                      TOP  (Back)