Step 1.

Choose Your Package

300 Sites ($799)150 Sites ($599)100 Sites ($399)

Choose Your Usernames

Choose the username you would like to claim and 3 alternates in order of preference. We suggest that your alternate choices be variants of your first choice (e.g. jonnysmith, jonny_smith, jonnysmithjr - must contain no spaces). In the event that your first choice is not available on a particular service, we will attempt to register the first available alternate. In the event that none of your choices are available for a particular service you will be notified in the report that we send out when your order is complete. Please Note: we will not attempt to register more than 4 choices on any single social network per order.

Username must be between 4-15 characters

*Username:

*1st Alternate:

*2nd Alternate:

*3rd Alternate:

Step 2.

Basic Information

We use this information only when a site requires it for registration,
in which case it might be publicly displayed.

For the First and Last Name fields, you may re-type your company name if you'd like that displayed instead - however, several sites do require an actual person's name, so please supply one in the "Alternate" first and last name fields.

*Company Name:

*First Name:

*Last Name:

*Alternate First Name:

*Alternate Last Name:

*Zip Code:

 Male Female

*Phone:

---JaunuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember ---12345678910111213141516171819202122232425262728293031 ---1901 1902 1903 1904 1905 1906 1907 1908 1909 191019111912191319141915 1916 1917 1918 1919 19201921 1922 1923 1924 1925 1926 1927 1928 1929 19301931 1932 1933 1934 1935 1936 1937 1938 1939 19401941 1942 1943 1944 1945 1946 1947 1948 1949 19501951 1952 1953 1954 1955 1956 1957 1958 1959 19601961 1962 1963 1964 1965 1966 1967 1968 1969 19701971 1972 1973 1974 1975 1976 1977 1978 1979 19801981 1982 1983 1984 1985 1986 1987 1988 1989 19901991 1992 1993 1994 1995 1996 1997 1998 1999 2000

* must be at least 18 years old.

Step 3.

Email Address

This E-mail address will NOT be used in the registration process (we create a separate email address for that).This e-mail address is used to contact you when your order is complete and/or to contact you if we require additional information in order to process your order.

*Your Email:

Step 4.

Your Primary Website

Please enter the URL of your primary website below. This link will be included in a majority of the profiles that we create for you. In addition to increasing the visibility of your primary website within all major social networks, having hundreds sites link back to it will improve the site's search engine rank!

*Your website:

Step 5.

Your Site Description

Space Chimp Media can ensure that your messaging is consistent across hundreds of social media sites.
The information below will be included in a majority of the profiles that we create for you.

*One Line Description (140 Characters or Less):

*Paragraph Description:

Step 6.

Your Logo

Space Chimp Media can help you ensure that your brand's logo and/or trademark is consistent across hundreds of social media sites. Please select an image to be included wherever possible within the sites on which we claim your name.

*Select Image (recommended square-shaped):

Step 7.

Legal Requirements

 I attest that I have read, understand and agree to the terms of use.

 I attest that I am the legal owner or legally authorized representative of the names to be claimed above.