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Hosting Application
Personal Details
First Name
Last Name
ID Number
Postal Address
Postal Code
Physical Address
City:
Postal Code:
Contact Details
Email Address:
Phone Number:
Cell Number:
Work Number:
Fax Number:
Company Details
You may omit this section if this is a private registration
Company Name:
Postal Address:
Postal Code:
Physical Address:
City:
Postal Code:
Hosting Details
Register my domain name on my behalf (annual domain name fees applicable)
I will register my own domain name and I will point the dns settings to Valente Hosting
Hosting Package:
V Micro R 5.99 pm
V Basic R 25.00 pm
V Standard R 65.00 pm
V Premium R 110.oo pm
V Platinum R 195.00 pm
Domain Name:
Billing Cycle (monthly annually):
Monthly
Annually
