| First Name : |
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| Last Name : |
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| Company name (if any) : |
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| Street Address : |
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| Postal Code : |
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| City : |
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| Country : |
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| Please give us a phone number where we can reach you : |
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| Fax Number (if any) : |
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| VAT number (if any) : |
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E-mail account :
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| Please select the formula you want : |
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| If you order an URL-redrection account please enter the destination URL. |
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| Domainname |
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You can order a new domainname using our online registrtation form at :
http://www.webhost.be/registreer_e.html , English version
http://www.webhost.be/registreer_n.html , Nederlandse versie |
| Payment method |
Bank transfert
Credit card (Visa or Eurocard (Mastercard) only) |
| Invoice |
Yes by postal mail
No, EMAIL only |
| Before processing your order, our sales service will send you a mail asking to confirm the information you entered are correct.
If you have questions or special requests, please enter them in the box below.
We will reply to your message BEFORE processing your order.
Ik aanvaard de algemene voorwaarden. I accept the general conditions. |
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in the field below.
this is a protection against misuse of this form. |