PowerActiveSite Website System

Secure Sign-up Form

Welcome to the PowerActiveSite secure sign-up form! You can use this form to sign-up for a PowerActiveSite website, or to request a free demo of the PowerActiveSite system. The information you submit below will not be shared with anyone, and will only be used for purposes of establishing a service account for your PowerActiveSite account. Complete the form and click the preview button to confirm your information. Once we receive your information, a service representative will contact you to begin setting up your PowerActiveSite website. Thank you!

Contact Person: *
Phone: * Cell Phone:
Email Address: *
Mailing Address: *
City: * State/Province: *
Postal Code: * Country: *
Phone: * Fax:
I would like to just schedule a free demo of the PowerActiveSite system at this time.
WEBSITE INFORMATION - If you are ready to purchase a PowerActiveSite website complete the website and payment information areas below.
I am ready to order a PowerActiveSite website package!
Please choose the package you want from the drop down:
What would you like for the main website header text?
(Example: Professional Fire Fighters of Glendale, AZ)
What would you like for a smaller sub header text?
(Example: Serving the city of Glendale since 1925)
Enter the domain name to use for this website:
(Example: www.iafflocal1234.org)
Does your organization already own this domain name?
Does your organization run an in-house email server?
If you have any initial requests or
questions, please enter them here:

How do you prefer to pay the one time
- PowerActiveSite package setup fee?
How do you prefer to pay the recurring
- PowerActiveSite web hosting fee?
If you selected Credit Card above, select Card Type:
Enter Card Number:
(NO dashes or spaces)
Enter Card Code:
(3-4 digit card verification number on back of card)
Select Card Expiration Date:
Click the Preview Order button once to continue. You will be able to confirm your order on the next page. You order is being submitted via encrypted transaction (SSL) for your protection.

(* Required Fields)