Great Buy Web Hosting  -  Reseller Credit Card Authorization Form

Fax: 1-800-303-0344  
(Please call this number first or your fax will not be accepted)

Please Print

1) Customer Domain Name ___________________________________________________

2) Card Type _______________________________________________________________

3) Card Number _____________________________________________________________

4) Expiration Date ________________________________

5) Name On Credit Card ______________________________________________________

6) Billing Address for Cardholder  (as shown on credit card statement)

___________________________________________________________________________

___________________________________________________________________________

7) Phone Number ____________________________________________________________

8) Contact Email _____________________________________________________________

9) As a Reseller for Great Buy Web 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 Reseller hosting plan are you signing up for (circle one)

         Reseller   ($39.75/mo - $25 set up) (Set up fees non-refundable)

         Tier2 Reseller   ($250/mo - $100 set up) (Set up fees non-refundable)

12)  What billing cycle are you signing up for (circle one)
  
      Monthly         Quarterly           Semi-Annual         Annual

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

14)  Photocopy of cardholder's pictured identification (preferably driver's license)

The cardholder agrees that Great Buy Web Hosting will automatically bill the
subscriber's credit card for their hosting account and for any of their resold
accounts until the subscriber notifies Great Buy Web Hosting 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  (Do Not Print)


________________________________________________  MM/DD/YY____________________




Great Buy Web Hosting is owned and operated by Dennis's Computer Graphics,
Niceville, FL.
All credit card charges will show Dennis's Computer Graphics on your statement.

To cancel your hosting account(s), please refer to:
http://greatbuywebhosting.com/cancellation.htm

Thank you for your cooperation and your business.

**Be sure to include your domain name on any correspondence so we can assist 
you quicker.

**Our Billing Department can be reached at:

1-866-303-344 Monday - Saturday 10am - 10pm CST
Email:  billing@greatbuywebhosting.com

***Your completion of this authorization form helps us to protect you, our valued
customer, from credit card fraud. All information entered on this form will be
kept strictly confidential. ***