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Authorization to Charge Credit Card or Debit Card
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AUTHORIZATION TO CHARGE CREDIT CARD
HighSpeedHostingSolutions.com 56 Reyburn Drive Henderson, Nevada 89074 702-837-3379 (Fax) |
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| 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:
Cardholder Signature ______________________________________ |
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