Hosting Account Application

Billing Details

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Domain Name Details

New domain registration? Check domain name availability here.

Domain Options *

Register a new domain - $99 for 2 year license.
Use an existing domain name that I have already registered.

Domain Name *

Alternate Domain Name

Domain Registrar Details

I.E. The registrar company that you registered the domain name with E.G. Webcentral

Registrar Company Name

Auth or EPP Code / Registry Key

Registrar Account Username

Registrar Account Password

Hosting Packages

Please select which hosting package you would like. Refer to our Hosting Packages & Prices (PDF) for further details and pricing.

Hosting Package *

Email Accounts

Do you wish to host your mail accounts with us? *

Yes
No

Payment Method

We prefer direct deposit. Upon receipt of your application, Secure eHost will email you a tax invoice for you to process your payment before we setup your account. To speed up this process, if we receive a bank receipt on payment then we can can setup your hosting account quicker.

Further Comments

Terms of Service *

I accept the terms of service in our Hosting Terms and Conditions (PDF).

By lodging this Application you confirm that you have read, understood, agree with and will conform to the Hosting Terms and Conditions (PDF) which are a separate document and form part of this Application. We recommend that this Application be completed with reference to the current Hosting Packages & Prices (PDF) document which details all services included.