Green Bird Media New Client Form

Please fill out the form below:

Client Info

Full Name:

Email:

Phone Number:

Domain Info

Domain Name:

Domain Registrar:

User ID:

Password:

Account Name or Number:

Hosting Info

Hosting Company:

User ID:

Password:

Account Name or Number:

Server platform

 Unix/Linux
 Microsoft IIS
 Other
(List other server type)

PHP and MySQL availability

 Yes
 No
 I don't know

Bandwidth Available:

Server Space:

FTP Info
(needed to upload files to your website)

Server:

User Name:

Password:

Initial Path:

Control Panel
(needed to configure your hosting setup, add email accounts, etc.
This may be the same as your FTP info)

User Name:

Password:

Email Configuration

E-mail Boxes (accounts) to create:

E-mail Boxes (accounts) to create:

E-mail Boxes (accounts) to create:

E-mail Boxes (accounts) to create:

E-mail Boxes (accounts) to create:

E-mail addresses for forms and contact links to go to:

Any configuration or account access needed for third-party integration

Log-in Page:

User Name:

Password:


Log-in Page:

User Name:

Password:

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