SEASIDE DATA SYSTEMS INC. PAYMENT AUTHORIZATION FORM
PLEASE PRINT FORM AFTER FILLING OUT ONLINE THEN FAX FORM TO 813-283-4916


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Customer Name
Cardholder Name
Email Address:
Office Phone
Credit Card Billing Address (street, city, state)
Zip Code:
Credit Card Mastercard
Visa
American Express
Credit Card Number
Expiration Date
Description of Services: Services with an asterix are a 1 time payment. All other services are recurrent monthly or quarterly charge.

Monthly Website 2.0                                         *Annual Website Services
Monthly Website Services                                 *Annual Landing Page
Quarterly Website Services                                *Seminar/Webinar
Monthly Google Adwords                                 *Domain Name Transfer
Other

Payment Amount
Payment Authorization I authorize Seaside Data Systems to automatically apply recurring payments to the card listed above for the described services. I understand these services can be terminated at any time by written request giving 30 days notice after the 1st year of initiation.
I authorize Seaside Data Systems to apply a single payment to the card listed above for the described service.
Outstanding Account Balances I authorize Seaside Data Systems to bill the card listed above for the full amount of any outstanding charges there may be on my account.
Does not apply.
Comment

SIGNATURE: I authorize Seaside Data Systems, Inc. to charge my credit card for the above described services.
DATE