Home
Empowerment through collective innovation

Service Request Form

Important Please fill out this form and we'll get back to you as soon as possible. Be aware that if you order a hosting account, we will create the account and send a bill to your address automatically.
Administrative Contact

Identification of the Contracting Party.

The username you would like to have for your Koumbit account, or the one already set up while opening a previous account. This username should have at least 4 and at most 16 characters, and should contain only non-accented characters, numbers, dashes (-) and underscores (_).

Entering your PGP key here will allow us to authenticate you and communicate securely.

Web Development

We install free and open source content management systems (CMS). The basic open publishing and interactivity applications (such as forums, comments, RSS feeds) are included by default, but need to be configured to suit your needs.

Please specify the additional items you may require.

Fill in this section if the functionality you need is not listed above. Enter your requests by priority.

$ CAD

Please enter your approximate budget for this project.

Hosting Services

Hosting service you are interested in.

I agree with Koumbit's Founding Principles, and I understand that a $10 membership fee ($30 for moral persons) will be added to my invoice. For more information see http://membres.koumbit.org/en/become_a_member

Enter your full postal address and, if needed, the name of your organization's accountant.

CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
10 + 7 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.