Data Management Group, LLC
Credit Card Authorization Form

We accept Visa, Master Card, American Express and Diners Club as a payment option.
To have your credit card charged for our services, we MUST have the following signed statement on file.

Accounts will be charged on the invoice date. There is no surcharge for using
credit cards as a form of payment.

Name as it appears on the Credit Card

Address where your statement is received

City where your statement is received

State where your statement is received

Country where your statement is received

Zip Code your statement is received

Work Phone

Home Phone

Fax

E-mail

Hosting Account Name

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Credit Card Type:   Visa    Master Card    American Express    Diners Club


Credit Card Number:     ___________-___________-___________-___________


Credit Card Exp.       ___________/___________


CVS Number from credit card ___

I authorize Data Management Group, LLC. to charge the credit card listed above
for any charges relating to my hosting account with Data Management Group, LLC
These charges include but are not limited to charges that I may accrue from month
to month, any work authorized by me via email or telephone and any past due balances
in order to bring the account to current status.
This authorization is valid until revoked in writing.



______________________     ____________________  _________
Name (signed)             Name (printed)         Date



Please fax this signed form back to us 24 hours a day at 904-879-1846
New accounts cannot be set up until this form has been received.