islandhosting.com
Credit Card Authorization Form 		islandhosting.com
1412 Quadra St.
Victoria, BC
V8W 2L1 Canada
[email protected]

This form authorizes Island Net AMT Solutions Group Inc. (D.B.A. Islandnet.com, D.B.A. islandhosting.com) to charge your credit card for any and all fees, recurring or otherwise, relating to your islandhosting.com account.

This form must be printed and filled out completely and the original must be received at our office within 10 days of account creation.

The following information must match what the credit card company has on file: Print your islandhosting.com username here (do not include your password):

_________________________


Print your credit card number here (we accept VISA and MasterCard):

_________________________

Print your card's expiry date here:

_________________________

Print the name of the cardholder here (as it appears on the card):

_________________________



Date: _______________

Signature: ____________________

Name: _________________________
Address: _________________________
_________________________
City: _________________________
Province/State: _________________________
Country: _________________________
Postal Code: _________________________
Phone: _________________________
The following information must match what is in your islandhosting.com profile:
Contact: _________________________
Address: _________________________
_________________________
City: _________________________
Province/State: _________________________
Country: _________________________
Postal Code: _________________________
Phone: _________________________
OFFICE USE ONLY: