On-Line Web Hosting Service
Application Form

To Apply for our hosting services, kindly fill in the form below and click the Submit Button when you are done.

Application Contact Details:

Administrative Contact:
Full Name
(as per Identity Card)		:
Identity Card No.
(for individuals only)		:
Date of Birth
(for individuals only)		:
Company Name
(for Corporate Clients) 		:
E-mail:
Office Phone Number:
House Phone Number:
Mobile Phone Number:
Fax Number:
SexMale
Female

Billing/Mailing Address Details:

Street Address:
:
:
City/State:
Postcode / Zipcode:
Country:


Server Application Details:

Hosting Packages:
Select the type of Web Hosting Package you would like to apply for :
[ Check out details of packages offered! ]


Preferred Web Server Operating System:
No Preference
Windows
Linux

Domain Name Details:

Domain Name to tag to this account :
[ Check the Availability of a Domain Now! ]
www. .

Company Registration No :
(Fill in only if you need us to register a .my domain for you)

Additional Features:
Additional Web Space Needed :

Number of FTP Accounts Needed :
(Each Additional FTP A/C costs RM60.00/annum with a setup cost of RM5.00)

List the required FTP LOGIN Usernames/Passwords you want:


Other Instructions:

Additional services, if any.

Miscellaneous:

How did you hear about XGEN Technologies Sdn Bhd ?

Please key in details or comments (if any)


I confirm that all information given above is true and complete. I hereby authorise XGEN Technologies Sdn. Bhd. to verify the information from whatever sources and by whatever means that XGEN Technologies Sdn. Bhd. may consider appropriate. I confirm that I shall be subjected to the rules and regulations governing the use of the applied service(s). I understand that XGEN Technologies Sdn. Bhd. reserves the right to reject any application without any due reason or terminate any existing account if the information provided herein is incorrect.

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