Secure Domain Registration Form
 Download a PDF of domain registration form

Please fill in the secure form bellow. Your information will be sent to us and we will acknowledge your request either via email or telephone. The information provided here will be used to register this domain please make sure it is accurate. Once registered any changes to the information below will be at an additional charge  by Network Solutions. Read Carefully 

Name: Address:
Company City:       
Province  Postal Code   Phone (H) 
(Business)  Fax    Email Address 
Login ID   Password  
Requested Domain Name
The Presidential  The CEO  The Manager Vanity Domain
$845.00* Yearly    $750.00* Yearly    $325.00 Yearly    $175.00*Yearly 
Fees Name Registration Fee $75.00   Cdn
FREE Name Move (requires the purchase of any domain) FREE   
Annual E-Mail @ your domain .com (virtual email only No webspace) $100.00 Cdn

Includes: one email address at your domain forward to your any existing email address

Payment Type VISA Mastercard
Card # Exp. Date
Name on Credit Card
This form constitutes an agreement between the Domain name holder and Western Canada Internet  to provide domain services  on Western Canada Internet's equipment for chosen domain package. NOTE! All Domains are subject to our standard policies located at http://www.westerncanada.com/policy.htm . All graphics must be clothed, no pornographic sites are allowed.
Authorization (Signature) You must Type I Agree In Space Provided. All Prices subject to G.S.T.
All domains names are subject to Registration  charges of $75.00 Cdn. this amount will be billed directly to your Credit Card (if a Card number is provided) by Western Canada Internet. Arrangements can be made for customers who choose not to use a Credit Card. Please call for details. These Registration charges are in addition to any hosting fees Western Canada Internet  may charge.
Refunds: No refunds will be provided for any name registrations submitted by Western Canada Internet. If you make a error in the name it cannot be changed without an additional fee being charged. Before submitting this form please read this form carefully once we receive an order it will be automatically processed.

All applications will be verified prior to any work being completed.