PersonalWeb Application Form

ORGANIZATION INFORMATION:

organization name ........: ____________________________________________

organization address .....: ____________________________________________

                            ____________________________________________

postal code ..............: __________

city .....................: ____________________________________________

country ..................: ____________________________________________

phone number .............: ________________

fax number ...............: ________________

e-mail adress ............: ____________________________________________



BILLING CONTACT:

name (first, last)........: ____________________________________________

organization .............: ____________________________________________

                            ____________________________________________

postal code ..............: __________

city .....................: ____________________________________________

country ..................: ____________________________________________

phone number .............: ________________

fax number ...............: ________________



ADDITIONAL INFORMATION:

requested 2nd level domain: _________________________________________.ch

requested URL ............: http:// _________________________________.ch

requested FTP account name: ________________ (max. 8 characters)

requested FTP password ...: ________________ (min. 8 characters)

requested disk space .....: O 10 MB     O 20 MB     O 50 MB     O 200 MB



place, date: ____________________   signature: _________________________