LA InterWeb - Reseller Credit Card Authorization Form

FAX: (818) 242-7064



1) Customer domain name _____________________________

2) Card type____________________________________

3) Card No.____________________________________________

4) Expiration date______________________________

5) Cardholder name_______________________________________

6) Cardholder billing (complete)

Address: ________________________________________________________________

______________________________________________________________________


7) As a Reseller for LA InterWeb, do you authorize recurring charges on your credit card
for your hosting account as well as any hosting accounts you sign up through your control panel?

         - if yes, please initial here __________

        
8) Credit card issuing bank phone

number:________________________________________________


9) What Web hosting plan are you signing up for(circle one)? 

Premium Reseller 

Commerce Reseller

Enterprise Reseller 


10) What billing cycle did you sign up for (circle one)? 

Monthly

Quarterly

Semi-Annual

Annual


11) Xerox copy of credit card (front and back), must be legible.


12) Xerox copy of cardholder's pictured identification.


The cardholder agrees that LA InterWeb will automatically bill the 
subscribers credit card for their hosting account and for any of their resold accounts
until the subscriber notifies LA InterWeb to cancel the account(s).
Cancellations must be made before the next billing cycle. (To see the first day of
your billing cycle, please click on 'Billing History' in your Control Panel).
Otherwise, cardholder will be responsible for current billing cycle.

13) Cardholder signature (MUST BE IN HAND WRITING)


___________________________________________________ MM/DD/YY________________


To cancel your hosting account(s), please refer to this page:  
http://lainterweb.com/products/webhosting/cancel.html

Thank you for your cooperation & your business.

(be sure to include your domain name on any correspondence, including check payments)    

Our Billing Department can be reached at:                               

Email:  billing@lainterweb.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.