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20759 Hardwick Oaks Dr. Houston,
TX 77073
Tel: 281-645-4086
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GroupWeb
Media LLC Payment Form
This form is for
GroupWeb EmailWire.Com clients who subscribe to our yearly/monthly payment
plans or other services. By signing this form
below, you agree that GroupWeb will charge your credit card each year/month
for the amount of ________ beginning from this date:
_________________________. Your card is charged same date every month for recurring
monthly plans, or on your anniversary date for the yearly recurring plan.
[ ] I am subscribing to monthly Plan
$198 charged today, then $99/month for one year.
[ ] I am subscribing to yearly Plan $999
charged today, then $999/year on your anniversary date.
[ ] Other Services/Plans. Specify
__________________________
Amount: ________
Payment
We currently accept
American Express, Visa, MasterCard and Discover.
Contact Person:
__________________________________________________________
Emailwire.com User
ID:______________________________________________________
Email address:
____________________________________________________________
Name on credit card: ______________________________________________________
Type of credit card: _____________________________________ CCV #: __________
Credit Card#: ____________________________________ Exp. Date:_______________
Company Name: __________________________________________________________
Tel: ____________________________________________________________________
Physical Address and zip code – same as on credit card.
________________________________________________________________________
________________________________________________________________________
Agreement:
By signing below, you agree that GroupWeb will charge your credit card for specific services or every
month for one year, or on your anniversary date for the yearly plan. You
agree that these charges are not refundable.
Signature: ____________________________ Today’s Date:
_____________________
Sign, scan and e-mail this form to info@groupweb.com.
Comments: How did you learn about us? Any special instructions? _________________________________________________________________________ |