PLEASE PRINT AND FAX FORM TO (480) 247-5131
Company Name:
Email Address:
CREDIT CARD BILLING ADDRESS Street:
Street Line 2:
City:
State:
Zip Code:
Business Phone:
Description of Purchase:
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Seaside Website Package
Google Adwords Service
Landing Page
Tools for Success Seminar
Quarterly Autopay Website Package (Renewal Only)
Other
Credit Card Type:
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Visa
Mastercard
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Credit Card Number:
Expiration Date:
Card Holders Name:
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Amount
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GOOGLE ADWORDS: I understand that I will incur a recurring charge on this credit card until I cancel service(s).
QUARTERLY RENEWAL: I understand that I will incur 4 total recurring charges on this credit card and am unable to cancel this service until all payments have been completed.
SIGNATURE
:
I authorize Seaside Data Systems to charge my credit card for the above service(s) and amount.
_______________________________________________________Date: _______________
