Apollo Hosting, Inc. - Reseller Credit Card Authorization Form

FAX:  

(800)861-0986 (United States)

(772)679-0508 (International) 


1) Customer domain name _____________________________

2) Card type____________________________________

3) Card No.____________________________________________

4) Expiration date______________________________

5) Cardholder name_______________________________________

6) Cardholder Billing Address (complete): 

_________________________________________________________________________

_________________________________________________________________________

7) Phone Number_________________________________________

8) Contact Email________________________________________


9) As a Reseller for Apollo Hosting, 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 __________

        
10) Credit card issuing bank phone

number:________________________________________________


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

RS-100

RS-200

RS-300

RS-400


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

Monthly

Quarterly

Semi-Annual

Annual 


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


14) Xerox copy of cardholder's pictured identification.


The cardholder agrees that Apollo Hosting, Inc. will automatically bill the 
subscribers credit card for their hosting account and for any of their resold 
accounts until the subscriber notifies Apollo Hosting, Inc. 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.

15) Cardholder signature (MUST BE IN HAND WRITING)


___________________________________________________ MM/DD/YY________________


To cancel your hosting account(s), please refer to this page:  
http://apollohosting.com/host/cancel.shtml

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:                               

1-877-525-HOST(4678) (Toll-Free) extension 4
1-512-261-1203 extension 4

Email:  billing@apollohosting.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.