Required Fields marked with*
	Your Name*	:
	Email*	:
	I do not wish to Renew	:	My domain name only My hosting account only Both my Hosting and Domain Name
	Domain Name / Hosting account to cancel*	:
	Domain Name / Hosting account Username*	:
	Domain's Password*	:
	Reason For Cancel*	:
	Is there anything we could do to stop you from canceling?*	:
	Daytime Phone Number*	:
	Will you recommend Flexihostings to your Friends?		Yes No
	Would you like us to contact you when we have something special to offer you? (Max. 4 times a year)		Yes No

I have read the cancel and refund policies and i accept the terms of each.

I understand and agree that the information provided below will be enteres into electronically, and all disclosures, notices or other related communications may be provided by electronic means. i give my consent to receive this Agreement and Communications in an electronic form.