DNS Central(tm) Domain Registration + Managed DNS + Forwarding Services

Managed DNS and Forwarding Service Sign Up

Domain Name

Organization Name

Address

City

State/Province

Postal Code

Country Code

Contact First Name

Contact Last Name

Voice Phone

Fax Phone

E-Mail Address

Select one service type:

Website/E-Mail Forwarding Service [$19 year]

Includes E-Mail forwarding and your choice of website forwarding, framed forwarding or coming soon web page. Forwarding options may be defined via online account maintenance after submitting this form.

Managed DNS [$19 year]

Managed DNS requires at least one static and unique IP address for your web site. The IP address is provided by your ISP or web hosting provider. More DNS zone information may be defined after submitting this form.

Default IP address to point domain to

Payment Information
Select payment type for your forwarding service or name service account. Note: If you choose to pay by check or other method, your account will not be activated until we receive payment.

Payment Type

Please complete the following information if paying by credit card.
Credit Card Number
Security Code	What is the security code?
Expiration Date
Cardholder Name
For verification purposes, please provide the card holder name, billing address (street or box), and billing zip or postal code as shown on your credit card statement.
Card Billing Address
Card Billing Postal Code

Account Password
Specify a password that you will use to maintain your account information (6 to 16 characters).

Special Instructions
Please specify any additional information that you think we may need to process this request.

Promotion Code
If you were given a "Promotion Code", please enter it into the field below. If you do not have a promotion code, but were referred by someone, please list who referred you here, otherwise just leave the field blank.

Submit Your Request
Your application will be processed as soon as possible. You will be notified via e-mail after your account has been activated.