You must fill out all applicable areas or your account may be held for processing. Do you accept our Usage/User Agreement? (you must select one) Yes No Organization: Last, First Name: E-mail address: Telephone (include area code): Street Address/Apt#: City: State or Providence: Oh OhioOutside U.S./CanadaAL AlabamaAK AlaskaAB AlbertaAS American SamoaAZ ArizonaAR ArkansasBC British ColumbiaCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMB ManitobaMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNB New BrunswickNF NewfoundlandNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern MarianasNT Northwest TerritoriesNS Nova ScotiaOK OklahomaON OntarioOR OregonPW PalauPA PennsylvaniaPE Prince Edward IslandPR Puerto RicoQC QuebecRI Rhode IslandSK SaskatachewanSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY WyomingYT YukonU.S. Armed Forces Americas Zip Code: Country: Check this box if you already have a domain registered through somewhere else. Registration Company (who do you want us to register your domain name through) FreeDomainMachine.com Length of registration 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 1 Year Domain Information (ex: www.yourname.com) Please replace the yoursite to the name of your domain. Domain Name: .net .org .biz .info .com We will need to user name/password protect your ftp/upload directory to our servers. Requested user name: Password:

Standard features included with all packages Free Domain Registration or transfer, no setup fees, email services, unlimited 24 hour a day FTP, Daily Site Statistics, Front Page Server Extansions, Active Server Page Support, Restricted members directory and online administration area, Access Counter, Form mail CGI. Additonal Features Front Page Extensions (Free) Password Protect Directory ($10.00 per month). Payment (you must select one) Your credit card will be billed for the amount you chose above by the company you chose to have register your domain. Your monthly hosting charges from BuckeyeNet can either be charged to your credit card or paid by money order/check. Without your credit card information we can not process your order. please contact us if there is some other way you would like to work out registration payment. Visa Mastercard Card Number: Expiration Date (mm/yy): Account hold name: Comments If you have and comments or were reffered by someone please let us know in this section.