PC Madness - Web and Hosting Services

Hosting Application Form Online

1. Personal Details:
* Denotes a required field - Your personal details will be held in strict confidence by PC Madness for the sole purpose of creating a Hosting Account and willl never be forwarded to a third party. View our full Privacy Policy.
First Name:*		Last Name:*
Business Name:		ABN:
Street Address:
Suburb or City:		State:		Postcode:
Email:*
Phone:*		Mobile:

2. Domain Details:
* If transferring a domain, please skip this step
Domain Name Requested:

3. Transfer / Renew My Domain
* If registering a domain, please skip this step
Current Domain Name:
Domain Password:
Previous Provider:

4. Hosting Options*
Please select ONE option below:
Green Package	Monthly ($16)		Annual ($170)
Yellow Package	Monthly ($22)		Annual ($240)
Blue Package	Monthly ($28)		Annual ($280)
Red Package	Monthly ($33)		Annual ($320)

Extra Requirements
Email Virus Scanning and Spam Filtering		$49.95 - 1 year
Online Statistics		Monthly ($10)		Annual ($100)
Domain Redirection		$30 - 1 year

Please note that all new hosting accounts attract a one-time setup fee of $25.



TERMS AND CONDITIONS: This form is the basis for a binding contract between you and PC Madness (upon confirmation). By submitting this form, you acknowledge that all information has been entered correctly. View our full Terms and Conditions.