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Email List Hosting, Website Hosting, and Domain Registration Request Form
Please use this form to request free email list hosting, website hosting, and domain registration for any individual or group underrepresented, underserved, or facing unfair bias, discrimination, or defamation online.

First Name: Middle Name: Family Name:
Street address:
City: State / Province:
Zip / Postal Code: Country:
Email address (not in any domain you are requesting):
Telephone number: Fax number: (include area and country codes for both numbers)
Organization name (or specify for "Individual Use"):
Description of organizational or individual activities and budget (brief):

I am requesting (check all that apply):
Email List Hosting
Email list name(s) requested (example treehuggers):

Email list domain preferred (examples, @groups.onlinepolicy.net, @groups.queernet.org, or at your OPG/Queernet-registered domain, see Domain Registration below)
Website Hosting
Web domain owned or reserved
(example, treehuggers.org, see Domain Registration below):

Web hosting username requested:
Web hosting password requested:
Domain Registration
I request creation or transfer
of this domain:

Domain service username requested:
Domain service password requested:
Additional services requested (may not yet be available):
Email account(s) (@onlinepolicy.net, @queernet.org, or at your OPG/Queernet-registered domain)
Online community forum / message board
Web site usage statistics
Other (please specify):

Are you 13 years of age or older?
Yes, I am 13 years old or older
No, I am under 13 years of age

The Online Policy Group (OPG) will not share the information you have provided without your permission:
OPG may share my information with other organizations (provides you with other interesting opportunities and helps OPG to exchange lists in order to do outreach and fundraising)
OPG may share my information only within OPG
OPG may not share or store my information except for email list hosting, website hosting, and domain administration

(Coming soon!) I have read and agree to the Terms of Service policy of the Online Policy Group, Inc.

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Online Access
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Digital Defamation
Digital Divide
Online Community
Diversity of Content
Online Commercialism
Electronic Electorate
Privacy Policy
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