synercom/edi Billing Profile Form

Thank-you for choosing synercom/edi as your Internet hosting provider and for taking the time to fill in this form. If you have any comments regarding these changes, or our service to you in general, please type these in the optional Comments box below.

You should only submit this form if you have received a letter from us asking you to do so; if you'd like another copy of our Hosting Policy document, you can download a PDF copy by clicking here.

Customer Information
Your Primary Domain (e.g. synercom-edi.com)
Company
Contact Name
Contact Title
Contact Email
Contact Phone	- -
Please choose a password for logging in to our system for on-line account management. Your Login ID will be your primary domain name (not including www).
Account Login Password

Billing Information
Billing Contact Name
Billing Contact Title
Billing Contact Phone	- -
Billing FAX	- -
Billing Email
Address 1
Address 2
City/Prov/Postal
Send Invoices Via	Email Acrobat PDF Email Word Document Fax Invoice Mail invoice (NOTE: A $2.50 per invoice enclosure charge applies)
Invoice Cycle Option	Advance Monthly Billing Explain... Advance Quarterly Billing Explain... Advance Yearly Billing Explain...

Hosting Information
Secondary Domains (If any, list all separated by commas)
Server Type	Please see Hosting Policies & Pricing for Details. Basic Web Hosting Package ($30.00 per month) Enterprise Web Hosting ($50.00 per month)
Email Accounts (list all on a separate line) These are actual email accounts with their own login's
Email Aliases (list name:alias_address each on a separate line) These are email addresses that will be forwarded to another email account. Example: somename:somename@otherdomain.com

Optional Information
Comments?