20759 Hardwick Oaks Dr. Houston, TX 77073
Tel: 281-645-4086   

GroupWeb 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 plan.

[  ] 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 __________________________  Amount: ________

We currently accept American Express, Visa, MasterCard and Discover.

Contact Person:  __________________________________________________________

Emailwire.com User ID:________________  Email Address:_______________________

Name on credit card: ______________________________________________________

Type of credit card: _____________________________________  CCV #: __________

Credit Card#: ____________________________________ Exp. Date:_______________
Company Name: __________________________________________________________

Tel: ____________________________________________________________________

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 info@groupweb.com.

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