| FULL NAME | [______________________________________] |
| DOMAIN NAME | [______________________________________] |
| ACCOUNT USERNAME | [______________________________________] |
| RESELLER HOSTING PLAN | [______________________________________] |
| CREDIT CARD NUMBER | [______________________________________] |
| CREDIT CARD EXPIRATION | [______________________________________] |
I understand and agree that should I dispute the above credit charge through my credit card issuer or credit provider, it will constitute a breach of contract as well as credit card fraud. I have included signed photocopies of front and back of credit card and valid identification as requested above. I understand that this information will be used for the purpose of verification for the credit card.
By signing below and submitting for payment, I acknowledge acceptance of the Terms of Service and Acceptable Use Policy. I also agree to waive any charge-back rights and in the event of a dispute, requests for cancellation must be submitted through the cancellation form located at http://www.resellerzoom.com/cancellation.html. This form and the photocopies of the credit card and valid identification must be received via fax, email or mail within 14 business days of account signup.
| CARDHOLDER SIGNATURE | [______________________________________] |
| DATE | [______________________________________] |
Please fax to: 832-422-9373
You can also scan and email to: billing@resellerzoom.com (Note: We recommend you edit out a few of the numbers before emailing to us for security reasons)
OR, mail to: Hosting Zoom, Inc. * 11200 Westheimer, Suite 900 * Houston, TX
77042 USA