Digital Faucet, Inc Authorization
to Charge Credit Card

NAME OF BUSINESS:  
WEB SITE:  
NAME ON CARD:  
EIN/SSN NUMBER:  
BILLING ADDRESS:  
  
CITY:  
STATE:  
PROVINCE:  
COUNTRY:  
ZIP:  
PHONE:  
EMAIL ADDRESS: 
 
CREDIT CARD NUMBER:  
3 DIGIT CVV NUMBER ON BACK OF CARD
(AMEX- 4 ON FRONT): 		 
EXPIRATION DATE:  

I, THE UNDERSIGNED, AGREE THAT DIGITAL FAUCET, INC. MAY CHARGE MY CREDIT CARD $99 FOR WEBSITE HOSTING FEES EACH MONTH.

I ALSO AGREE TO BE BOUND THE TERMS OF THE DIGITAL FAUCET HOSTING AGREEMENT AND ACCEPT THAT THE CHARGES WILL CONTINUE UNTIL I PROVIDE WRITTEN NOTICE OF TERMINATION.

UNDER PENALTY OF PERJURY, I AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER AND I AM THE CARDHOLDER NAMED ON THE CARD.

Authorized Card Holder's Signature
 DATE
Print Authorized Card Holder's Name

Please complete & fax to us at 512-233-0737

FORM PROPERTY OF DIGITAL FAUCET AND MAY NOT BE USED WITHOUT PERMISSION