DynIP US & International Registration Form

Registered DynIP Customer
First Name   Last Name  
Company  
Address  
   
City   State/Prov.  
Zip/Postal Code   Country  
Telephone  
E-mail address  
Registration Key
(from About Tab)
 
Service Options
Quantity (yrs.) Service Price (US $ /year) Total
  DynIP Basic $29.95  
  DynIP Pro
Domain Name:
$69.95  
  DynIP Enterprise Edition
Domain Name:
$199.95   
  Subtotal  
Plus 13% Tax (GST/HST #898246574RT) 13%  
Total Enclosed  

Payment Method

Check  
Money Order  
MasterCard  
Visa  
American Express  

Credit Card Information

Card Holder Name  
Card Number   Expiry Date  
Signature  
Credit card customers please note that you will be billed in Canadian funds,
and that the exchange rate will appear on your card statement!

Date  

Please mail or fax the completed form to: CanWeb Internet Services Ltd.
1086 Modeland Road
Building 1010 - Suite 201
Sarnia, ON, N7S 6L2, CANADA
Fax: +1 (519) 332-6464

You will be sent confirmation of your payment by e-mail.
US Customers: Please note that US $0.63 is required for mail to Canada!
   Thank You!