20759 Hardwick Oaks Dr. Houston,
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
[ ] I am subscribing to $199 monthly
plan: I am paying today $2 setup fee plus 1st month, then later
pay $199/month for 11 months.
[ ] I am subscribing to yearly plan $1500
charged today then $1500/year on your anniversary date.
[ ] Other Services/Plans. Specify
We currently accept American
Express, Visa, MasterCard and Discover.
Name on credit card: ______________________________________________________
Type of credit card: _____________________________________ CCV #: __________
Credit Card#: ____________________________________ Exp. Date:_______________
Company Name: __________________________________________________________
Physical Address and zip code – same as on credit card:
By signing below, you agree that GroupWeb will charge your credit card
monthly, quarterly, or yearly on your anniversary date for the recurring plan(s).
You agree that these charges are not refundable.
Signature: ____________________________ Today’s Date:
Sign, scan and e-mail this form to firstname.lastname@example.org.
Comments: How did you learn about us? Any special instructions?