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Fax
Authorization
for Visa or MasterCard
Domain
Name....................................................................
Name of
Cardholder...................................................................................................................
Billing
Address.......................................................................................................................
...................................................................................................................
Country....................................................................
Card Type Visa
....................MasterCard...........................................
Card
Number.........................................................................................
Expiry
Date..........................................................................................
Amount Authorized
Hosting @ C£
per
month until written cancellation
Set-up
fee once off at C£50
or C£
Total
amount in words
please
.........................
...
I hereby authorize you to debit my account for the amounts stated above.
Signature of cardholder
...............................................................................................................
Today's Date....................................................
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