Fax this completed form to (504) 566-0484. Payments will be processed within two business days. Please include US$10 processing fee in your payment.
Account Information
Company / Organization Name:
Contact Individual:
directNIC Username:
Telephone: ( ) Email:
Order Information
Domain Name Service Name and Period
(For example: renewal for 2 years)
Billing Information
I authorize Intercosmos Media Group to charge this credit card US $
My card is a (circle one): Visa MasterCard American Express Diner00 Club
The name appearing on the card is:
The card number is:
The card expires on:
The card00 billing address (if different from above)
Street Address / Suite:
City:
State/Province:
Country: Postal Code:
Attention: BillingdirectNIC Domain Service Fax-In Order Form
Print Name Date Signature
