EMAIL ADDRESS:

DOMAIN NAME: HTTP://

CREDIT PROVIDER: 

NAME ON CARD: 

CREDIT CARD NUMBER #: 

EXPIRATION DATE:

THREE DIGIT SECURITY CODE ON BACK OF CARD - LAST 3 DIGITS:

AMERICAN EXPRESS CARD ID NUMBER:

BILLING ADDRESS:

BILLING CITY & STATE/COUNTRY:

BILLING ADDRESS ZIP CODE:

I authorize Bulkin Enterprises, Inc. (d/b/a highspeedhostingsolutions.com) to debit my credit card as a monthly recurring charge or annual charge for their services rendered at agreed upon published prices.  I also have reviewed the Acceptable Use Policy & Service Agreement, received a copy of this agreement and agree to the terms and conditions outlined in the Service Agreement. Charges on my credit card statement will appear from highspeedhostingsolutions.com  I certify that I am the cardholder and these charges are authorized.

Cardholder Signature ______________________________________ 

Date ________________