Personalized Web Pack

To prevent the unauthorized use of your credit card, we require this authorization form to be completed.

• Fill out the form legibly – print all information
• Authorize the charges to your credit card by signing below
• All prices are plus tax of 12%

[_] BEST option - both sites for a year, $75 to set up and $180 a year (approx. $15/month) to host both, a total $255.

[_] Retailing site for a year, $50 set up and $100 a year to host – total $150

[_] Recruiting Site for a year, $$50 set up and $150 a year to host – total $200

Total Payment for the 1 Year Plan: __________ (plus tax)

Automatic Renewal [_]Yes [_]No

[_] Monthly Payments Start Date: _________________ Recurring Date: _______ of each month.

Total recurring charge amount: $ __________ (plus tax)

$15 Retail Site

$20 Recruiting Site

$25 Both Sites

Monthly plan runs for a minimum of 3 months and may be cancelled at any time after that date. Details below.

Credit Card Information

Card Number ______________________________________ Expiration ______________

Type of Credit Card: ___________________

Card Holder Name: _________________________________________________________

Your Name: ________________________________________________________________

Card Holders Billing Address (as it appears on the credit card statement)

Notes: _______________________________________________________________________________

_____________________________________________________________________________________

Please confirm the amount you are authorizing: $ ________ 1 Year Plan $_______ per month.

As the credit card holder, I understand that by signing this form, I am hereby authorizing Wayde Drain to charge my credit card for the amount I confirmed above. I understand that for the Monthly Plan, charges will occur monthly. I will notify Wayde Drain in writing to change or stop any future recurring charges. I hereby affirm that I am legally able to authorize this sale and agree to pay the above total according to the card issuer agreement. I authorize receipt of said monthly charges and understand that all sales are final.

_______________________________________________ ________________________

Card Holder Signature Today’s Date

All information entered on this form will be kept strictly confidential.