(Please Print Clearly)
I hereby authorize Attorneys Access Inc. to charge my ___________________ [Visa/MasterCard/American Express/Discover] credit card, with credit account number _________________________________ [credit card number] _______________[expiration date] ________ [Security Code On Back Of CC] in the amount of US $100.00 for my/our Law Firm DOMAIN Hosting On Attorney Access Servers for 1 Full Year.
I agree to pay this amount according to the card issuer agreement. I understand there will be absolutely no refunds or charge backs under any circumstances whatsoever.
I also authorize Attorneys Access Inc. to charge my credit card of a one time fee for the total full amount above.
__________________________________
__________________________________
(please sign on the above line)
(please print your name above)
Dated: ___________________
First Name: ________________________ Last Name: _____________________________________
Law Firm: _________________________________________________________________________
Address: __________________________________________________________________________
City: ______________________________________________State: _______Zip: ________________
Telephone: __(______)_______________________ Fax: __(_______)__________________________
DOMAIN NAME: ______________________________________________________________________
email: _____________________________________________________________________________
All information entered on this form will be kept strictly confidential and secured.
Please fax this completed form by fax to AttorneysAccess Inc. FAX: 1-714-754-7070
Note: After we receive your completed form we will process your payment within 24 hours and send you or your Law Firm an email giving you instructions to your NEW Hosting account on our servers.