<HEAD>
<STYLE TYPE="text/css">
<!--


  <TR>
    <TD colSpan=2 vAlign=top>
      <HR>
    </TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>First Name:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT 
  name=Vorname></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>Last Name:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT name=Name></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>Company Name:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT 
name=Firma></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>Telephone:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT 
  name=Telefon></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>Fax:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT name=Fax></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>E-mail:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT 
  name=e-mail></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>Address:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT 
      name=Straßezlig;e></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>Zip Code:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT name=PLZ></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>City:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT name=Ort></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>State (Province):</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT 
name=state></FONT></FONT></P></TD></TR>
  <TR>
    <TD bgColor=#ffdead vAlign=top>
      <P><FONT face=Arial><FONT size=2>Country:</FONT></FONT></P></TD>
    <TD vAlign=top>
      <P><FONT face=Arial><FONT size=2><INPUT name=Land></FONT></FONT></P></TD></TR>
  <TR>
    <TD colSpan=2 vAlign=top>
  
    </TD></TR>
  <TABLE BORDER=0
ALIGN=CENTER width=50%
CELLSPACING=1
CELLPADDING=0><tr><td COLSPAN=2 VALIGN=TOP> <HR></td></TR><tr><td
COLSPAN=2 VALIGN=TOP> <P><FONT
FACE=Arial><FONT
SIZE=2>You can omit this paragraph, if you want only to "park" your domain.</FONT></FONT></P></td></TR><tr><td COLSPAN=2
VALIGN=TOP> <P><FONT
FACE=Arial><FONT SIZE=2>You have four choices for the connection of your domain:</FONT></FONT></P></td></TR><tr><td BGCOLOR=#FFDEAD
VALIGN=TOP> <P><FONT
FACE=Arial><FONT SIZE=2>10 mb
webspace with unlimited traffic and e-mail accounts  on our server for 60 US-Dollars per year.</FONT></FONT></P></td><TD
VALIGN=TOP> <P><br><FONT
FACE=Arial><FONT SIZE=2><INPUT TYPE=TEXT NAME=webspace1
SIZE=20></FONT></FONT></P></td></TR><tr><td BGCOLOR=#FFDEAD
VALIGN=TOP> <P><FONT FACE=Arial><FONT SIZE=2>Choose free webspace without banner and pop-up window for me
:</FONT></FONT></P></td><TD VALIGN=TOP> <P><br><br><FONT
FACE=Arial><FONT SIZE=2><INPUT TYPE=TEXT
NAME="subdomain Ihrer
Wahl1" SIZE=20></FONT></FONT></P></td></TR><tr><td BGCOLOR=#FFDEAD
VALIGN=TOP> <P><FONT
FACE=Arial><FONT SIZE=2>Redirect the domain to my subdomain/domain
:</FONT></FONT></P></td><TD
VALIGN=TOP> <P><br><br><FONT
FACE=Arial><FONT SIZE=2><INPUT TYPE=TEXT NAME="Meine subdomain2"
SIZE=20></FONT></FONT></P></td></TR><tr><td BGCOLOR=#FFDEAD
VALIGN=TOP> <P><FONT
FACE=Arial><FONT SIZE=2>Primary Name Server:
IP-Number:</FONT></FONT></P></td><TD VALIGN=TOP>
<P><FONT FACE=Arial><FONT
SIZE=2><INPUT TYPE=TEXT NAME=nameserver1nr
SIZE=20></FONT></FONT></P></td></TR><tr><td
BGCOLOR=#FFDEAD VALIGN=TOP> <P><FONT
FACE=Arial><FONT SIZE=2>Primary Name Server:
Name:</FONT></FONT></P></td><TD VALIGN=TOP> <P><FONT
FACE=Arial><FONT
SIZE=2><INPUT TYPE=TEXT NAME="nameserver1 name"
SIZE=20></FONT></FONT></P></td></TR><tr><td
BGCOLOR=#FFDEAD VALIGN=TOP>
<P><FONT FACE=Arial><FONT SIZE=2>Secondary Name Server:
IP-Number:</FONT></FONT></P></td><TD
VALIGN=TOP> <P><FONT
FACE=Arial><FONT SIZE=2><INPUT TYPE=TEXT NAME=nameserver2
SIZE=20></FONT></FONT></P></td></TR><tr><td BGCOLOR=#FFDEAD
VALIGN=TOP> <P><FONT FACE=Arial><FONT SIZE=2>Secondary Name Server:
Name:</FONT></FONT></P></td><TD
VALIGN=TOP> <P><FONT
FACE=Arial><FONT SIZE=2><INPUT TYPE=TEXT NAME="nameserver2 name"
SIZE=20></FONT></FONT></P></td></TR>
<p><tr><td BGCOLOR=#FFDEAD
VALIGN=TOP> <P><FONT FACE=Arial><FONT SIZE=2>I order 2000 web templates for 99 US-Dollars
:</FONT></FONT></P></td><TD VALIGN=TOP> <FONT
FACE=Arial><FONT SIZE=2><INPUT TYPE=TEXT
NAME="2000 web templates" SIZE=20></FONT></FONT></P></td></TR>
 </TABLE BORDER>
<TABLE BORDER=0 ALIGN=CENTER width=50% CELLSPACING=1
CELLPADDING=0><tr><td COLSPAN=2 VALIGN=TOP>
<HR></td></TR><td>

  
  <TR>
    <TD colSpan=2 vAlign=top>
      <P align=right><P><FONT face=Arial><FONT size=2>Your space for
      additional orders and comments:</FONT></FONT></P></TD></TR>
  <TR>
    <TD vAlign=top>
      <P align=left><FONT face=Arial><FONT size=2><TEXTAREA cols=40 name=body rows=7></TEXTAREA></FONT></FONT></P></TD>
    <TD vAlign=top>
      <P align=left></P></TD></TR>
  <TR>
    <TD colSpan=2 vAlign=top>
      <HR>
    </TD></TR>
	
	<TR>
		
		    <TD vAlign=top>
		
			
			
			<P><FONT FACE=Arial><FONT SIZE=2>You can withdraw the costs of the ordered domains from my credit card.</FONT></FONT></P></td><TD VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2><INPUT
			TYPE=CHECKBOX NAME=abbuchen
			VALUE=abbuchen></FONT></FONT></P></td></TR><tr><td BGCOLOR=#FFDEAD
			VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2>Credit card type:</FONT></FONT></P></td><TD VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2><INPUT TYPE=TEXT
			NAME="credit card type"
			SIZE=20></FONT></FONT></P></td></TR>
			
			<tr><td BGCOLOR=#FFDEAD
			VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2>Name on the credit card:</FONT></FONT></P></td><TD VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2><INPUT TYPE=TEXT
			NAME="Credit card owner's name"
			SIZE=20></FONT></FONT></P></td></TR>
			
			
			<tr><td BGCOLOR=#FFDEAD
			VALIGN=TOP> <P><FONT FACE=Arial><FONT
			SIZE=2>Credit card number</FONT></FONT></P></td><TD VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2><INPUT
			TYPE=TEXT NAME=credit card number
			SIZE=20></FONT></FONT></P></td></TR><tr><td BGCOLOR=#FFDEAD
			VALIGN=TOP> <P><FONT FACE=Arial><FONT
			SIZE=2>Expiration date:</FONT></FONT></P></td><TD VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2><INPUT
			TYPE=TEXT
			NAME=expiration date
			SIZE=20></FONT></FONT></P></td></TR>
			<tr><td BGCOLOR=#FFDEAD
			VALIGN=TOP> <P><FONT FACE=Arial><FONT
			SIZE=2>Credit card issuing bank:</FONT></FONT></P></td><TD VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2><INPUT
			TYPE=TEXT
			NAME=credit card issuing bank
			SIZE=20></FONT></FONT></P>
			<br>
		You can fax also your credit card datas to +49 221 9252272.
		
		<TD
            VALIGN=TOP><tr><td BGCOLOR=#FFDEAD VALIGN=TOP>
            <P><FONT FACE=Arial><FONT SIZE=2>I pay the registration
            by Pay Pal to secura@web.de </FONT></FONT></P></td><TD VALIGN=TOP> <P><FONT
			FACE=Arial><FONT SIZE=2><INPUT
			TYPE=CHECKBOX NAME=Paypal
			VALUE=Paypal></FONT></FONT></P></td></TR>
	  
	
	
	
 
  <TR>
    <TD colSpan=2 vAlign=top>
      <HR>
    </TD></TR>
  <TR>
    <TD colSpan=2 vAlign=top>
      <P><FONT face=Arial><FONT size=2>By clicking at the button you accept our 
      <A href="http://www.domainregistry.de/tradeconditions.html">trade 
      conditions</A>,  <a href=http://www.icann.org/en/registrars/registrant-rights-responsibilities-en.htm>Registrants rights and responsibilites</a> and the <A 
      href="http://www.domainregistry.de/disputeresolution.html">Uniform Domain 
      Name Dispute Resolution Policy</A> of the Internet authority ICANN. These 
      documents are the base of the business relationship between you and Secura 
      GmbH concerning domain registration. </FONT></FONT></P></TD></TR>
  <TR>
    <TD colSpan=2 vAlign=top>
      <P><FONT face=Arial><FONT size=2><FONT color=#ff0000>By contract with 
      ICANN we are enforced only to connect pre-paid domains. Please do pay at 
      once in advance. You will get a bill and a confirmation about your domain 
      registrations. </FONT></FONT></FONT></P></TD></TR>
  <TR>
    <TD vAlign=top></TD>
    <TD vAlign=top></TD></TR>
  <TR>
    <TD vAlign=top>
      <P><INPUT type=submit value="I order these domains"></P></TD>

</table>
<BLOCKQUOTE>
    <BLOCKQUOTE>
      <BLOCKQUOTE>
        <BLOCKQUOTE>
          <BLOCKQUOTE><BLOCKQUote><p>
		          <P>
		  			Do you want a secure website?<br>
			<a href=http://www.domainregistry.de/certificates.html>Get Verisign SSL Certificate cheaper than at Verisign!</a>
            <P><A 
            href="http://www.domainregistry.de/biz-domains.html">.biz-domains</A> 
            <A 
            href="http://www.domainregistry.de/name-domains.html">.name-domains</A> 
            <A 
            href="http://www.domainregistry.de/eu-domains.html">.pro-domains</A> 
            <A 
            href="http://www.domainregistry.de/eu-domains.html">.eu-domains 
            </A><A 
            href="http://www.domainregistry.de/pro-domains.html">.info-domains</A> 
            <A 
            href="http://www.domainregistry.de/coop-domains.html">.coop-domains</A> 
            <A 
            href="http://www.domainregistry.de/museum-domains.html">.museum-domains</A> 
            <A 
            href="http://www.domainregistry.de/aero-domains.html">.aero-domains</A>
            <P><A href="http://world.std.com/cgi-bin/recommend">Recommend this website to your friends</A> 
    </P></BLOCKQUOTE></BLOCKQUOTE></BLOCKQUOTE></BLOCKQUOTE></BLOCKQUOTE></B 
  lockquote></CENTER></BLOCKQUOTE>

-->
</STYLE>
</HEAD>


