HOSTMAX Reseller Application Form Company: Contact Name: E-Mail: Address: City: State: Zip: Phone: Fax Number: Reseller Level: Silver - $150.00 Setup | $150.00 Monthly Min. Gold - $250.00 Setup | $250.00 Monthly Min. Platinum - $500.00 Setup | $500.00 Monthly Min. Kryptonite - $1000.00 Setup | $1000.00 Monthly Min. Payment Method: Credit Card Check Other Comments:
