Credit Card Authorization Form - Insynq
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1Credit Card Authorization Form
Date:_____/_____/__________
I ________________________________ authorize Insynq, LLC. to charge my credit/debit card listed below,
st
starting on the date services are first requested and on the 1
day of the month for each following through
to termination of services for the amount of monthly services, as adjusted from time to time, due to addition
of services rendered or deletion of services rendered.
Services rendered may include some or all of the following service options:
Virtual Desktop(s)
Third Party Application(s) Integration
Application(s) Hosting
Third Party Hosting/Licensing Fees and Surcharges
Data Storage
Setup and Modification Fees
Custom Services
Data Returns - Service, Shipping & Storage Device
Offsite Backup(s)
Application Testing Fees
Software Sales
Tax Where Applicable
Consulting Fees
Other New Services Added From Time to Time
Credit Card Information:
Name as it appears on the Card: __________________________________________________________
As the Individual card holder, I hereby authorize this card to be used for the deposit required.
As the company representative, I hereby authorize this card to be used for the deposit required.
Card Type:
□ VISA
□ MASTERCARD
□ DISCOVER
□ AMERICAN EXPRESS
Credit Card Number: ___________- ___________-___________- ___________
Expiration Date: ___/___/_____ Security (CVV) Code ________________________
Credit/Debit Card Billing Address: Street: __________________________________________________
City: ______________________State:____Postal Code: __________
I ________________________________ hereby authorize this card to be charged for service and/or final
payment, until Insynq, Inc. has been notified of cancellation by sending written notice by email or fax.
Cardholder/Company Rep. Name Printed
Company Name
Signature
Date
Billing Email Address
Billing Phone #
This Authorization can be faxed to 888.774.7507 or emailed to
Payment and orders cannot be placed until the completed form is received.
Insynq, LLC | 3312 Rosedale St., Suite 203, Gig Harbor, WA 98335 | 253.857.9400
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Parent category: Business