Speedfox, Inc. - Credit Card Authorization Form

FAX:(800)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 cardholder's pictured identification.
11) Which hosting plan are you signing up for? (circle one)  3 Star, 4 Star, 5 Star, or VPS Hosting

** NOTE: The cardholder agrees that Speedfox, Inc. will automatically 
bill the subscribers credit card each term specified above until the subscriber
notifies Speedfox, 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 send an email to support@speedfox.com

Thank you for your cooperation & your business.

(Be sure to include your domain name on any correspondence, including check 
payments.)                                   

1-512-261-1101

Email:  billing@speedfox.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.