Channel Request - created by phpFormGenerator

Channel Request - by www.maxfrag.net

Please fill out the form below to request a private channel.

Channel Name * What do you want the channle name to be?
Channel Password * Since this is a private channel, what do you want the password to be?
Which Free Server? * Select one of these free servers
Your Ventrilo Username *
Admin Password * What do you want your admin password to be, in case we want to give you admin to your channel.
Email Address *
Country

Type the following: For security purposes, please type the letters in the image.