Apollo Hosting, Inc. - Credit Card Authorization Form

Your completion of this authorization form helps us to protect you, our valued customer, 
from credit card fraud.  All information entered on this form will be kept strictly confidential.

Thank-you for helping us fight credit card fraud.

Instructions: 

1.  Xerox copy of Credit Card (front and back), must be legible.

  
2.  Please complete this form and fax, email or mail it along with a a copy of your
drivers license and Xerox copy of credit card to Apollo Hosting.

Fax: (512) 492-8488 (United States)/(512) 492-8493 (International)

Email: accounting@apollohosting.com

Mailing Address: 3267 Bee Caves Rd, Ste 107-191, Austin, TX 78746-6773 


1) Customer domain name _____________________________

2) Card type____________________________________

3) Card No.____________________________________________

4) Expiration date______________________________

5) Cardholder name_______________________________________

6) Cardholder billing address (where your credit card statements come to): 

_________________________________________________________________________


_________________________________________________________________________


_________________________________________________________________________


7) What is the initial charge for signing up for hosting that you authorize

to be charged to your credit card? ___________________________________ 


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

Value				VPS Lite			
	
Business			VPS Standard

Ecommerce Pro			VPS Advanced

				VPS Premium

Domain Name Registration Only


9) What billing cycle?  (circle one)

Monthly

Quarterly

Semi-annual

Annual 


The cardholder authorizes both the initial charge of signing up specified above, and 
agrees that Apollo Hosting, Inc. can automatically bill the subscribers credit card
each term specified above until the subscriber notifies Apollo Hosting, Inc. 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).  Otherwise, cardholder will be responsible for current billing cycle.

Cardholder signature (MUST BE IN HAND WRITING):


________________________________________________ MM/DD/YY________________


To cancel your hosting account, please refer to this page for directions:  
https://secure.apollohosting.com/order/ssl/cancel.php.

Be sure to include your domain name on any correspondence, including check payments.              

Thank you for your cooperation & your business,

Apollo Hosting Billing Department
www.apollohosting.com    

877-525-HOST(4678) Extension 4 (Toll-Free)
757-898-8666 Extension 4