PI Mall - Application Form

General Information

* First Name:
* Last Name:
* Company:
* Address:

* City:

* State:

* E-mail:
* Company Phone:	--
Company Fax:	--

For Hosting (PIMall hosts your site as well as linking it)

Provide the name you have ALREADY registered with Network Solutions or another website registrar

Website URL:

Do you need your website created?	Yes No

If you need your website created, please select up to 5 email addresses to use

Email 1:
Email 2:
Email 3:
Email 4:
Email 5:

Do you want Anti-Spam protection turned on?

Yes No

If you need your website hosted, and would like to have FTP access to your account, please provide
us with an FTP account name (for uploading your pages)


FTP Account Name Desired:

For Links Only (Your site is already designed and hosted by another, you would like a link inside the PI Mall)

Website URL:
E-mail Address:
Section To Be In:	PI INFO-BROKER PI STORE

Website Keywords

Keyword 1:
Keyword 2:
Keyword 3:
Keyword 4:
Keyword 5:

States You Are Licensed In

State 1:
State 2:
State 3:
State 4:
State 5:

Search Engine Optimization (rank higher in search engines)


Would you like to be contacted about improving your ranking in the major search engines?	Yes No

Contact Information

Phone Number:	--
E-mail:
NAIS Number:

PI Mall Mailing List


Do you wish to be added to the following mailing lists?
PI Mall Alerts:	Yes No
PI Classroom:	Yes No
NAIS Alerts/Updates:	Yes No
Security Alerts:	Yes No

Email Address To Send Alerts To: