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Gushi Systems Web Hosting Signup

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Please fill out this form completely. We reserve the right to request verification of all information entered below. Anything I have decided to put in this horrid yellow color is required and the form will probably vomit on you if you don't make it happy.

Please note all information is collected in accordance with my privacy policy, which is simply put as: "I don't share this info with anyone else without a subpoena, except possibly a single staff member who may help me do clerical work. Your information does not leave Gushi Systems." The exception of course is when a domain is registered in your name, you must understand that this information is publicly viewable.

Part 1: Basic Information:

Name:


First	Last	Nickname

Birth Date:
Note:This field is required for COPPA compliance, I only require my users be over 13 to comply with this law. If you're not 18, don't worry.


Month	Day	Year

Legal Address:

Address Line 1
Address Line 2
City
State
Zip Code (US Only)
Country
Area Code (include Country code if applicable)
Phone Number

Electronic Addresses:

Current E-Mail Address (Note:Do NOT list your desired domain name here unless you have it set up somewhere else or you will not be contactable.)
AOL Instant Messenger ID
ICQ Number

How did you hear about us?
If the above is another user, please tell us who

Domain Information:

Desired Domain Name
(please include suffix)

Please choose:

I already have registered this domain name.

I will register this domain name myself.

Please register this domain name for me for an additional $10.00

Hosting Information:

Desired Username (Note that this is only for logging onto the server, this will not affect your email address, a temporary password will be given to you upon setup.)
I require a SQL Account set up. The username will be (for security, we assign passwords)
Check here if you do not need or want a shell account.

I will send a check or money order to:

Dan Mahoney
PO Box 173
Selden NY 11784

Within 5 days of submitting this form.

I will pay via PayPal

Please contact me to arrange alternate payment arrangements.

Finally, please prove that you're not one of the many bots that's been abusing this form.:

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