CREDIT CARD AUTHORIZATION FORM Rev 1.1
I, ____________________________, authorize Host NIT Inc. to charge to the
following described credit card the amount equal to the value of the product I have agreed
to purchase in my subscription agreement or manual payment every month.. The amount shall be equal the total retail value
of the product minus the discounted percentage given to me at sign up, plus any applicable
sales taxes.
By signing this form, I agree with all terms and conditions of the sale/order, as specified in the Host NIT Inc™ Service Agreement(TOS) , which I have made over the phone, by fax, or via the Internet. I also authorize any additional Credit Card transactions I may make in the future to Host NIT Inc™, applied towards recurring monthly service fees, as well as any additional services or service upgrades, that I request on my account, and any applicable usage charges.
By signing this form, I agree with all terms and conditions of the sale/order, as specified in the Host NIT Inc™ Service Agreement(TOS) , which I have made over the phone, by fax, or via the Internet. I also authorize any additional Credit Card transactions I may make in the future to Host NIT Inc™, applied towards recurring monthly service fees, as well as any additional services or service upgrades, that I request on my account, and any applicable usage charges.
Card Holder's Name on Card: ___________________________________________
Cardholder's Contact Information, including billing address:
Street Address: ______________________________________________________
Suite/Apt. No.: ___________ City: _____________________________________
State/Province/District: ________________________________________________
Country: ___________________________ Zip Code: _______________________
Billing Address Phone: _________________ Alternate Phone: _________________
Email Address: _______________________@_______________________________
Signature: ___________________________________
Printed Name: _____________________________ Date: _____________________
Account Identifier : ___________________________________
(ie;
Order Tracking
# / Invoice #
/ Account #
CREDIT CARD AUTHORIZATION FORM
Please fax back to: 904-779-3323
ATTN
:
BILLING DEPT
Or
Send via Email w/attachments to auth@hostnit.com