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This is the non-java version of this sign-up form, to use the java version, upgrade your web browser to Netscape 3.0 or higher.

Please complete this form to apply for a TIBS account. Fill in all entry fields provided and answer questions appropriately. All information will remain confidential between TIBS and the applicant.

You will be contacted by telephone to confirm your application before we activate your account. This validation process prevents unauthorized use of an individual's identity. You must be 18 years or older to obtain a TIBS account or purchase TIBS services.

First Name:              
Last Name:               
Date of Birth (MM/DD/YY):

Company Name (Optional): Street Address: (P.O. Boxes not allowed)
City: State/Province: Zip/Postal: -
Country: Daytime Phone: -- Ext. Evening Phone: -- Fax Number: -- Existing E-mail Address: Alternate Address:


TIBS can host one or more domains for e-mail and Web pages. If you wish to register a domain, please enter desired names in the spaces provided. We will let you know if any or all are available. Domain Registration charges are $100.00 per domain for InterNIC fees for the first two years. TIBS charges a one-time $50 fee for each domain for any/all DNS maintenance

I would like TIBS to register the following domain(s):

Desired Domain 1:     
Desired Domain 2:     
Desired Domain 3:     
Desired Domain 4:     
I would like to transfer my existing domain.
Transfering Domain:      
Your NIC (handle with InterNIC):  

Services Requested

I am ordering the following accounts or services:

Services Quantity Price (per month) Set-up Fees
Web Access Account $ 15 a month $ 10
Pop3 E-mailbox $ 5 a month $ 5
Virtual Web Server $ 5 a month N/A
Virtual E-mail Services $ 5 a month N/A
Virtual Anonymous FTP $ 5 a month N/A
Autoresponders $ 5 a month N/A

Billing Information

Requested Billing Plan:
 Yearly (discounted)

Credit Card Network:

         Visa  Master Card  AmEx  Discover

Credit Card Number:     
Expiration (mm/yy):     /
Name appearing on card: 
    (only enter this name if different from name given above)

How did you hear about TIBS?

Additional comments

Sales Representative (Optional):

If you agree to be bound by this subscriber agreement, enter your name in the space provided below and click the "I ACCEPT" button.

Your full legal name:

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