Hosting Zoom, Inc.
11200 Westheimer, Suite 900* Houston, TX 77042 * USA

Credit Card Verification Form
Hosting Zoom requires submission of this credit card verification form to Hosting Zoom within 5 business days of account signup. This credit card verification form helps us protect you, our customer, from credit card fraud. Hosting Zoom keeps all information on this form in strict confidentiality.

Please print out this form and fill in all required information providing a signature acknowledging that you agree to our TOS and AUP. Include photocopies of the front and back of the credit card and driver's license or government issued identification.
FULL NAME [______________________________________]
DOMAIN NAME [______________________________________]
ACCOUNT USERNAME [______________________________________]
HOSTING PLAN [______________________________________]
   
CREDIT CARD NUMBER [______________________________________]
CREDIT CARD EXPIRATION [______________________________________]

I hereby authorize Hosting Zoom, Inc. to debit my above-mentioned credit card for all fees for the services that I had purchased from Hosting Zoom, Inc.

I understand and agree that should I dispute the above credit charge through my credit card issuer or credit provider, it will constitute a breach of contract as well as credit card fraud. I have included signed photocopies of front and back of credit card and valid identification as requested above. I understand that this information will be used for the purpose of verification for the credit card.

By signing below and submitting for payment, I acknowledge acceptance of the Terms of Service and Acceptable Use Policy. I also agree to waive any charge-back rights and in the event of a dispute, requests for cancellation must be submitted through the cancellation form. This form and the photocopies of the credit card and valid identification must be received via fax, email or mail within 5 business days of account signup.

CARDHOLDER SIGNATURE [______________________________________]
DATE [______________________________________]

Please fax to: 832-422-9373
You can also scan and email to: billing@hostingzoom.com (Note: We recommend you edit out a few numbers before emailing us for security reasons)
OR, mail to: Hosting Zoom, Inc. * 11200 Westheimer, Suite 900* Houston, TX 77042 USA