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Authorization to Charge Credit Card or Debit Card
AUTHORIZATION TO CHARGE CREDIT CARD

HighSpeedHostingSolutions.com
56 Reyburn Drive
Henderson, Nevada 89074

702-837-3379 (Fax)
INSTRUCTIONS:  Please print clearly & fax this form to highspeedhostingsolutions.com. If you do not have access to a fax the form can be mailed.  We accept Visa, MasterCard, Discover, American Express & PayPal.


YOUR  NAME:

EMAIL ADDRESS:

DOMAIN NAME: HTTP://

NAME ON CARD: 

CREDIT CARD NUMBER #: 

EXPIRATION DATE:

AMERICAN EXPRESS CARD ID NUMBER:

CSC 3 DIGIT NUMBER ON BACK OF CARD:

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. I certify that I am the cardholder and these charges are authorized. Charges on my credit card statement will appear from highspeedhostingsolutions.com

Cardholder Signature ______________________________________ 

Date ________________