Web Hosting Groups, 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._______________________________________ CVC Code:______________________________________ 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) Budget, Standard, Business, Enterprise, Virtual Private Server Account, Reseller, or Dedicated Server ** 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: /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.