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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