Provide Credit Card

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General Information

Your Name(*)

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Your Email(*)

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Your Phone(*)

Format example: 123-456-7890

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Credit Card Information

Cardholder Name(*)

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Billing Address(*)

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Billing City(*)

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Billing State(*)

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Billing Zip Code(*)

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Credit Card Number(*)

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Expiration Date Example: 01/22/2022(*)

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CCV Code (3 or 4 digit)(*)

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Indicate Authorized Charges

You may charge my card without my signature for the following: Check All that Apply(*)

You may charge my card without my signature for the following: <font size="1" color="#6cace0"><b>Check All that Apply</b></font>

Work that I order and/or approve via email or phone.
My Monthly Recurring Hosting Fees.
My Monthly Payment Plan / Milestone Payments / Deposits.
My Monthly Recurring Support Maintenance Charges.
My Annual Software Charges.
My Annual SSL Certificate Charges.

My Monthly Web Service Fees.
My Monthly Email Service Fees.
My Website Changes or Updates.
My Monthly Marketing Fees.
My Monthly Search Engine Packages or Prep Work.
A One Time Charge (Please Identify In Box Below).

Please Check One Choice

Use this space to tell us any Specific Instructions

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Terms & Conditions Approval

I have read the Terms & Conditions
(NOTE: If terms are not accepted, no work will proceed):(*)

<h4 style="margin-top: -5px; margin-bottom: -10px;">Terms & Conditions Approval</h4> <br/> I have read the <a style="color: white; href="https://qwdservices.com/index.php/products-services/services/index.php?option=com_content&view=article&id=60&catid=11&Itemid=619&Itemid=619">Terms & Conditions</a><br><style="font-size:10px;">(NOTE: If terms are not accepted, no work will proceed)</style>:

I Approve & Accept the Terms & Conditions
I Decline & Do Not Accept the Terms & Conditions

Please Accept or Decline Terms & Conditions

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Cardholder Signature(*)

Sign Above

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Help Us Fight Spam
If your numbers don't go through - hit refresh and try again(*)

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USE THIS CARD TO CHARGE ME WITHOUT MY SIGNATURE