Request for a New Hosting Account

Please fill out this form to request our hosting services. Be aware that an account will be created as soon as possible, and a bill will be sent to you automatically.

Administrative Contact

Identification of the Contracting Party.

First Name: *

Last Name: *

E-mail Address: *

Phone Number:

Name of Organization:

Koumbit Username: *

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 8 characters, and should contain only non-accented characters and/or numbers. NO dashes (-) and NO underscores (_).

Available Packages: *

A - 100$/year - 2 Go disk space, 5 Go/month bandwidth

B - 200$/year - 5 Go disk space, 15 Go/month bandwidth

C - 300$/year - 15 Go disk space, 30 Go/month bandwidth

Billing Address: *

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

Technical Contact (if different from Administrative Contact)

Name and coordinates of the person empowered to make decisions with regards to access levels, site maintenance and other technical issues within your organization. (He/she can be your webmaster or system administrator, for instance.)

Technical Contact First Name:

Technical Contact Last Name:

Technical Contact E-mail Address:

Technical Contact Phone Number:

Other Info

All other relevant information and special requests that will help us better serve you.

Other Info:

PGP Public Key:

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

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Math question: * 12 + 0 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

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Request for a New Hosting Account

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