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Credit Card Authorization
VPS Hosting is an MDM Enterprise Company
Customer Number: ____________(found on Invoice) <-- please fill in
Company Name: ____________________________ <-- please fill in
Email Address: ____________________________ <-- please fill in
Name On Card: ____________________________ <-- please fill in
Billing Address: ____________________________ <-- please fill in
City: ____________________________ <-- please fill in
State/Province, Zip: _________________ _________ <-- please fill in
Credit Provider: ____________________________ <-- please fill in
Credit Card Number: ____________________________ <-- please fill in
Expiration Date: Month: _______ Year: _______ <-- please fill in
3 or 4 Digit Code: _____ (found on back of card) <-- please fill in
I authorize VPS Hosting, an MDWA
Holdings, Inc. Company to debit my credit card as a monthly recurring charge
for their services rendered at agreed published prices. Should I dispute
a charge through my credit provider this will constitute a breach of contract
and will result in immediate deactivation of my virtual server. This agreement for recurring credit card transaction is valid from 11/21/2008 to ____/____/_____ (MM/DD/YYYY).
Signature ______________________________________ Date ________________
PLEASE NOTE: On your Bank Statements,
all charges from VPS Hosting, will appear as MDWA Solutions.
INSTRUCTIONS
After you have reviewed complete the Billing Authorization Agreement,
please print, sign, date, and fax the Acknowledgment of Receipt and Execution
of Agreement (this document) to VPS Hosting (480-461-9312). Mail
original to VPS Hosting at address indicated below.
VPS Hosting
6543 East Omega Street
Mesa, Arizona 85215
US
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