DEDICATED SERVER ORDER FORM


.::.
Please fill out the form accurately to ensure prompt setup of account .::.

Account Information

Please enter your personal information below.

First Name :
Last Name:
Street Address:
City/State/ZIP : ,
Country :
Phone Number :
E-Mail Address :
Confirm E-Mail :

Account Details

Please enter your server account details below.

Server Name:
Login Username:
Login Password :
Confirm Password :
Package To Order :
Operating System:

Payment Details

Please enter your payment details below.
We accept VISA, MasterCard and American 
Express As well as checks and money orders.


Credit Card    Check Money Order
Credit Card Number:
Expiration Date :
Amount To Charge :
Comments Or
Requests :

  

Please Note : All credit cards will be charged by Marcomb Inc
our parent company, also note, there is no setup fee for any dedicated server.

To pay by check, money order or western union,
send payment to :

Marcomb Inc
1210 Grace Hadaway Ln
Lawrenceville, GA, 30043
United States

 

 

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