Credit Card Authorization Form

Overview:
This credit card authorization form is required for your purchase in order to validate your
accounts payment, and to protect you (the consumer) and us (the provider) from fraud. We
understand that this is most likely and inconvenience and we sincerely apologize. You will never
be asked for this again unless the card you wish to have on file should change.

Instructions:
Please fill out these two pages with your information. Print and sign the signature page. In
addition, photocopy the front of your credit card and photo ID either on this form or on a
separate page. If you wish you can blur all but the last 4 digits of your card number, for your
privacy.

Please do Not Forget to Attach your Credit Card and Photo ID

Full name on the Hostwinds.com account/order (If different than card holder’s name)

russel williams
_______________________________________________________________________

Credit Card Holder Information:

russel williams
Full Name: _______________________________________________

3 Gordon St
Address: _______________________________________________

Canberra
City, State, Zip: _______________________________________________

Australia
Country: _______________________________________________

Hostwinds LLC
12101 Tukwila International Blvd
Suite#320
Seattle, Washington 98168
 +61402134796
Daytime Phone Number: _______________________________________________

By signing this Credit Card Authorization Form, the BUYER executing this form on behalf of the
CARD HOLDER represents and warrants to Hostwinds LLC that he/she is authorized by the CARD
HOLDER to make purchases and that the information set forth above is accurate and complete.
Furthermore, the CARD HOLDER acknowledges and agrees that all purchases from Hostwinds
LLC will be charged to the credit card identified above and are subject to Hostwinds LLC’s terms
of service and policies which are outlined here:

http://www.hostwinds.com/TOS.html

The BUYER and CARD HOLDER also agree to the monthly charges that are set forth in the order
form for the service plan signed up for which has been processed online. BUYER and CARD
HOLDER further understand his/her account will be canceled without refund should he/she
violate anything outlined in the terms of service and that all payments made for services
delivered are final and non-refundable.

Print Card Holder Name

russel williams
________________________________________________________________

Full Card Number

4902 9240 1302 2746

__________________________________________________________________

Card Holder Signature

________________________________________________________________

Date Signed

07/23
________________________________________________________________

Hostwinds LLC
12101 Tukwila International Blvd
Suite#320
Seattle, Washington 98168