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Web Hosting Groups, Inc. - Credit Card Authorization Form
FAX800)863-6499 (United States)
(419)781-4726 (United States)
(44 870)124-3293 (United Kingdom)
1) Customer domain name___________________________
2) Card type______________________________________
3) Card No._______________________________________
4) Expiration date________________________________
5) Cardholder name________________________________
6) Cardholder billing (complete)address
________________________________________________________________
________________________________________________________________
7) Does the cardholder authorize for recurring charge in the future?
- if yes, please check here __________
8) Credit card issuing bank phone number:
__________________________________________________
9) Cardholder signature (MUST BE IN HAND WRITING):
__________________________________________MM/DD/YY________________
10) Xerox copy of credit card (front and back), must be legible.
11) Xerox copy of cardholder's pictured identification.
12) Which hosting plan are you signing up for? (circle one)
All-in-One, Power, Power Plus, Virtual Private Server Account,
Deluxe Reseller, Basic, Deluxe, Commerce, Commerce Reseller, Professional, Professional Reseller
13) Is this account a Virtual Private Server account? Yes or No (circle one)
** NOTE: The cardholder agrees that Web Hosting Groups, Inc. will automatically
bill the subscribers credit card each term specified above until the subscriber
notifies Web Hosting Groups, Inc. in writing to either cancel the account or
stop credit card billing, before the next billing cycle (To see the first day
of your billing cycle, please click on "billing history" in your control panel).
To cancel your hosting account, please refer to this page for directions:
http://websitesource.com/company/cancel.shtml
Thank you for your cooperation & your business.
(be sure to include your domain name on any correspondence, including check
payments)
1-877-HOST-001 (toll-free) or 1-512-608-9990
Email: billing@websitesource.com
** Your completion of this authorization form helps us to protect you, our
valued customers, from credit card fraud. All information entered on this
form will be kept strictly confidential.