Jan Veuger Internetdiensten - Package subscription

With the form below you can request for subscriptions to QwikZite/Website/Email Packages.
After receipt of your information, we may contact you for additional details, if necessary. As well, we will ask you to confirm your subscription request.

Fields marked with * are obligatory.

Information about applicant:

Organisational or personal name:
(will become the official domain name holder)

Address:
(no post office box)

Zip code/place:

Country:

Postal address:
(if different from above adress)

Zip-code/place:

Country:

Contact person:

Function:

Phone number:

Email:
(existing email address)

Information about kind of package/subscription:

Kind of package:

QwikZite Package

QwikZite Light Package

QwikZite at subdomain

Website Package

Website Light Package

Email Package

Email Light Package

Kind of subscription:

Annual Subscription

Quarterly Subscription

Information about domain:

Package installation under:

Existing domain name:

New com/net/org/info/biz/eu-domain:

New nl-domain:

If you apply for a new nl-domain:
Did you earlier register a nl-domain name under the above organisational or personal name?

yes, a domain already registered:

Remarks:

In the box below you can express additional wishes, such as details about possible name servers of your own, etc.

Did you fill out everything?
We advise you first printing this form for your own convenience.
Subsequently, press the button below to submit your subscription request.

Jan Veuger Internet Services - P: Postbus 2599, 4800 CN Breda, The Netherlands T: +31-6-244 33 608 F: (+31)-84-830 77 66 E: info@janveuger.com - W: www.janveuger.com

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