Payment Authorization Form

Attention:
Fax:
Email:

Doteasy Billing Department

1-604-608-6832
billing@doteasy.com

To process your domain registration/web hosting order, we required that you complete
this payment authorization form and return to us by fax along with the photocopy of
the FRONT and BACK of your credit card.
Note: This application will be declined if we do not receive the completed form
within 48 hours.
By completing and returning this form, I authorized Doteasy Technology Inc. to process
this domain registration/web hosting service order and process the applicable charge(s)
on my credit card as provided below:
Date:
Domain Name:
Credit Card Type:

31-08-2015
www.iqbalshare.org
[ . ] Visa

[ ] MasterCard [ ] Amex

*Amex card will be charged in CAD at an exchange rate of 1.39

Credit Card Number:

Expiry Date:
Card Holder's Name:
Card Holder's Billing
Address:

4355443506797013
03/17

CVV:

Muhammad Iqbal
3010 NW 12th PL
Gainesville Florida 32605

Card Holders Phone

Number:
Signature

580-977-4041
iqbal

635