NDC Host Credit Card Auth Form

To:

NDC Host

Fax:

1-949-388-9069

From:

Date:

Re:

CC# Auth

Pages:

I herby authorize NDC Host (www.ndchost.com) to initiate charges to the credit card listed below, and authorize the credit card institution to accept the amount of such charges to the credit card listed below.

I understand that the credit card listed below will be automatically charged on a regular basis and a prepayment for services to be provided. I understand that if a charge is declined by the credit card institution, this is treated the same as a check returned for insufficient funds (NSF free), and may result in a $20 fee being added to my account.

I understand that I must provide NDC Host with notice of my request to discontinue this Credit Card Authorization.

I also understand that the Terms and Conditions (TOS) located on the NDC Host website www.ndchost.com as provided to me upon subscribing to the service governs use of the service in all respects.

Domain Name:
Credit Card Type:	Visa | MasterCard | JCD
(circle one)	Discover/Novas | Amex | Diners Club
Name on Credit Card:
Last 8 Digits of CC#
Billing Address:
Signature*

Please complete this form and fax it to NDC for initialization of service. This form is required!