Please complete all applicable sections. Any field marked with an asterik (*) is required.

REGISTRATION / BILLING INFORMATION*

Company/Billing Name:	____________________________
Your Name:	____________________________
Address line #1:	____________________________
Address line #2:	____________________________
City:	____________________________
State:	____________________________
Zip/Postal:	____________________________
Phone:	____________________________
FAX:	____________________________

CHOICE OF BILLING*

[ ] Invoice
[ ] Credit Card

Please Circle: MasterCard - Visa - American Express

Card Number:	_______________________________
Expiration Date:	_______________________________

INTERNET DOMAIN INFORMATION

Domain #1:*	__________________________________
Domain #2:	__________________________________
Domain #3:	__________________________________
Domain #4:	__________________________________

DIALUP CONNECTION INFORMATION

Enter the number of connections under the appropriate service type. You will be contacted for usernames and passwords.


[    ] 28.8k-56k Unlimited
[    ] 28.8k-56k Dedicated
[    ] ISDN 64k Unlimited
[    ] ISDN 64k Dedicated
[    ] ISDN 128k Unlimited
[    ] ISDN 128k Dedicated

EMAIL INFORMATION

If any EMAIL address is to be forwarded to another address then list that address; otherwise leave the "Forward To" Field blank.

--- PASSWORDS MUST BE AT LEAST 6 CHARACTERS ---

	EMAIL ADDRESS	FORWARD TO	LOGIN NAME	PASSWORD
EMAIL 1	___________	___________	___________	___________
EMAIL 2	___________	___________	___________	___________
EMAIL 3	___________	___________	___________	___________
EMAIL 4	___________	___________	___________	___________
EMAIL 5	___________	___________	___________	___________
EMAIL 6	___________	___________	___________	___________
EMAIL 7	___________	___________	___________	___________
EMAIL 8	___________	___________	___________	___________
EMAIL 9	___________	___________	___________	___________
EMAIL 10	___________	___________	___________	___________
EMAIL 11	___________	___________	___________	___________
EMAIL 12	___________	___________	___________	___________
EMAIL 13	___________	___________	___________	___________
EMAIL 14	___________	___________	___________	___________
EMAIL 15	___________	___________	___________	___________

FTP / FRONTPAGE INFORMATION

Will you or your designer be using Frontpage and/or ASP Server Extensions ? Yes [ ] No [ ]

Preferred Login Name:	___________________________
Password:	___________________________

OPTIONAL SERVICES

Please select any optional services you will need:

[ ] Secure Server (SSL)
[ ] Second-level Domain Name
[ ] CGI Scripting
[ ] Streaming audio/video
[ ] Shopping Cart

I AUTHORIZE ST. LOUIS INTERNET, INC. TO REGISTER OR TRANSFER THE ABOVE DOMAIN NAMES AND CONFIGURE SERVICE AS SPECIFIED.

Signed:	__________________________________
Print Name:	__________________________________
Date:	__________________________________