Shared Hosting Application Form

If you need assistance with this form please call us on +44 1624 825278 or email us on info@domicilium.com.

Name
Title
Company (if relevant)
Address
VAT Reg No (if relevant)
(VAT Reg No. only necessary for applicants from EU countries to avoid being charged VAT)
Telephone
Fax
E-mail
Hosting Platform	Linux Microsoft
Existing domain name or domain name required	.co.uk .com .co.im
Other prefix (please specify ie.org)
Webspace	25Mb Other
Other amount (please specify)
Email required	Yes No
Email address (1) (ie sales@)
Email address (2)
Email address (3)
Email address (4)
Email address (5)