First Name:
(John)

Last Name:
(Smith)

Username:
(pick a username)

Password:
(MySecret)

Contact email address:
(fred@yahoo.com)

Requested Plan
Affiliate Web site Only ($15 a month + a $10 setup fee)
Affiliate Web site and ISP Service ($29.95 a month + no setup fee)
(If you never intend to get the ISP service, Please select the first option)
(If you intend to get the ISP service select the second option, you will be charged for the first plan and credited the setup fee when the ISP service is available)

Requested Site:
http://www.myhdi.com/
(Enter fred if you want your site to be http://www.myhdi.com/fred)

Requested Email Address:
@myhdi.com
(Enter fred is you are requesting an email address of fred@myhdi.com)
(note: will also work at @myhealthdynamics.com)

E-mail Password:
(password for the requested email address)

You will be contacted via email if your requested options are not available or when your site has been configured..