PIIAI Member Website Project
Template Development

Comlete this form if you have your own URL (web address) already registered, AND have your website already created.


I.      Please provide us with the URL for your agency.

My URL is:
http://


II.     Contact Information.

Contact Name:
Agency Name:
Phone#:

X.      Additional Services

Additional E-mail boxes are $2 per box, per month, or choose a 10-pak of e-mail boxes for $13.95 per month.    PIIAI templates come with one e-mail box, so please fill in the first e-mail box.  If none are desired, please leave blank, and select "Please establish an account for monthly billing".

Please use the format of, "___________@myURL.com"










Charges less than $10 per month must be billed to a credit card.  Charges in excess of $10 can be billed.  To set up credit card billing, please print out, and fax the credit card payment form.

Please establish an account for monthly billing.
I understand that my charges will be more than $10 per month and a to set up payment via credit card. I understand that no other charges will be billed unless they are pre-authorized by me.  (click on credit card payment form, and fax this form to (217) 241-6001)

 

For personal website design or special alterations to your current website, please contact EOS, inc. at (800) 241-6006 for consultation and estimates.



2000 EOS, Inc. All rights reserved