Automatic Credit Card Billing Authorization Form

Shepherd Hosting

Automatic Credit Card Billing Authorization Form

If you would like to enjoy the convenience of automatic billing, simply complete the Credit Card Information section below, sign the form and fax it to us at (503) 343-9772. All requested information is required. Upon approval has been received, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by notifying us in writing.

Customer Information (To be completed by merchant)

Customer name:		Customer account number:		Phone:
					-		-

Payment Information (To be completed by merchant)

I authorize Shepherd Hosting to automatically bill the card listed below as specified:

Amount: $

Frequency: Weekly Monthly Quarterly Annually (Check only one)

Start billing on:

End billing when:		Contract expires:
		Customer provides written cancellation

Credit Card Information (To be completed by customer)

Shepherd Hosting accepts the following credit cards: Visa, MasterCard, American Express

Credit card type:		Credit card number:		Expires:
				/

Cardholder's name:		Card verification code:

(as it appears on credit card)		(on back of credit card)

Cardholder's address:		Cardholder's Zip code:

(as it appears on credit card)		(as it appears on credit card)

Customer's signature:		Date: