North Star Marketing-Communications, Inc
North Star Marketing-Communications, Inc.
Automatic Credit Card Billing Authorization Form
Please complete the form below for submission in our automatic recurring billing for monthly website hosting and up-front fees including domain transfer and domain registration. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us.
Customer Information
Customer Name:
Customer Phone Number:
Payment Information
I authorize North Star Marketing-Communications, Inc. to automatically bill the card listed below as specified.
Monthly Hosting Amount: $ per month
Domain Registration Amount: $15 per domain per year
Please note: Monthly hosting costs will start on the first day after the client completes their CMS training. That month will be pro-rated depending on the training date, after which the full amount will start on the 1st of the following month.
Credit Card Information (To be completed by client)
North Star Marketing-Communications, Inc. accepts the following credit cards: Visa, MasterCard, American Express, and Discover.
Credit Card Type (please circle): VISA MC AMEX DISCOVER
Credit Card Number: ________________________________________________
Expiration Date: _______________
Cardholder’s Name (as shown on card): ________________________________
Cardholder’s Zip Code (required): _______________
Customer Signature: ________________________________________________
Date: _______________
Billing Contact Information (To be completed by client)
Name of Billing Contact: ____________________________________________
Phone Number for Billing Contact: ____________________________________
Email Address for Billing Contact: ______________________________________
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