Customer Information
Customer Name:	*
Company Name:
Phone Number:	* A representative will need to be able to call you back at this phone number.
Address:	*
City:	*
County/Province:	*
Postal Code:	*
E-mail Address:
Do you already own a Domain Name?	Yes No (If you already own a Domain name there will be no charge for domain name registration)
Current/Desired Domain Name:	http:// *
	Note: Domain names are based on availability.
	The domain name is used for your web address and e-mail addresses. For example, http://www.janedoehomes.com/.
How did you hear about us?:	*
	If you were not referred by anyone, or any place simply type in "N/A".
System Information
System Setup Fee:	- Select Package - EstateAgentSites Normal Package Customised Web Solution *
Hosting Plan:	- Select Hosting Plan - EsateAgentSites Hosting  40.00/month Custom Hosting Solution *
Note: Your first month of web hosting & setup fee IS DUE AT CONFIRMATION OF YOUR SIGN-UP. You are billed the hosting fee on a monthly basis. There is no contract, and you may cancel anytime.
Billing Information
Please check your preferred payment method. We will contact you by telephone to process: Credit Card PayPal Cheque (must be in euros drawn on a French bank or in US dollars drawn on a US bank) SWIFT