Website Hosting Registration | dazil Internet Services

Website Hosting: Registration

(The information you provide will be maintained as a confidential, secure record. Your information will be transmitted using a technology called Secure Sockets Layer (SSL), which encrypts (or encodes) sensitive information before it is sent over the Internet.)

Website Information:
Website URL*

(eg. https://www.mysite.com)
Is the Domain Name Registered?*
- Yes
- No
- Not Sure
Domain Registration*
- Please register the domain for me
  ($19.95/year)
- I will register the domain name myself
Contact Information:
Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Email*
Billing Preferences:
Payment Method*
- Credit Card
- Bank Transfer
- Cheque
Please make the payment once you have received the invoice.

Please make cheque payable to:

dazil Internet Services
627 Thurston Terrace
Port Moody, BC
Canada V3H 4J2
Please make the payment once you have received the invoice.

If paying via Interac e-transfer, please send to to customersupport@dazil.com.
Credit Card Information:
Credit Card Type*
Credit Card Number*
CSV/CVV Code*
Expiry Month*
Expiry Year*
Terms of Service*
- I have read and agree to the Terms of Service

Website Hosting: Registration

Website Information:

Contact Information:

Billing Preferences:

Credit Card Information: