AUTHORIZATION TO CHARGE CREDIT CARD
         Reseller ID: 
        Company Name:                               
       Email Address:                               <-- please fill in
        Name On Card:                               <-- please fill in
     Credit Provider:                               <-- please fill in
  Credit Card Number:                               <-- please fill in
     Expiration Date:                               <-- please fill in
I authorize Verio Web Hosting, Inc. to debit my credit card as a monthly recurring charge for their services rendered at agreed published prices. Should I dispute a charge through my credit provider this will constitute a breach of contract and will result in immediate deactivation of my virtual server.

I have included a photocopy of the credit card both front and back and have signed the photocopy. 

 
Signature ______________________________________   Date ________________


INSTRUCTIONS
Please print, sign, date, and fax to Verio Web Hosting, Inc. (801-437-0202). Mail original to Verio Web Hosting, Inc. at address included below.