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Designing Sign-up Form

Please complete the following form and we will get started on setting up your "NEW" website. If you have any trouble with our forms or questions beforehand please contact us by e-mail support@bjmmedia.com
    


*ALL FIELDS ARE REQUIRED*
Step 1:
Please enter your personal information below.
Name:
Company Name:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Current E-Mail:


Step 2:
Please enter your domain information below.
Domain Name:
Password: (must be 8 characters)
Confirm Password: (must be 8 characters)


Step 3:
Please enter your credit card information below.
Credit Card:
Credit Card Number:
Expiration Date:
Signature on Card:
(must match subscriber)


Step 4:
Please select your payment schedule below.
Monthly*
($145.00 per month)
Quarterly*
($413.25 every 3 months)
Yearly*
($1,566.00 per year)
Bid Proposal*
(we will contact you)


* Please be aware that the above cost includes web hosting and domain name purchase. We will contact you with the specs of the hosting package and the estimated time to complete your website.
Step 5:
Please take some time to answer the following questions:

Where did you hear about our designing service?
Advertisement
Sales Representative
Word of Mouth
Other

Would you like us to send your information to the email address listed above?
Yes
No, if no we will call you with your information


Step 6:

DISCLAIMER:



You are accepting the above statements

Please be advised that only valid email addresses will be accepted!




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