Sirrus Web Technologies accepts Visa, Mastercard and American Express as a payment option. To have you credit card charged for Sirrus Web Technologies services we MUST have the following signed statement on file. Accounts will be charged on the invoice date. Ther e is no surcharge for using credit cards as a form of payment. All fields are required:

Name (as it appears on the credit card): ________________________________________

Address where CC statement is received: ________________________________________

Address where CC statement is received: ________________________________________

Address where CC statement is received: ________________________________________

City: ________________State/Prov: ______Zip:________

Country:_____________________________________

Domain Name/Account Logon: __________________________

Email Address: ______________________________________

Phone number:________________________________

Card type (Visa, MC, Amer Express): __________________

Card number:_________________________________

Expiration month/year:_______________________

I authorize Sirrus Web Technologies to charge my Visa/Mastercard/American Express account for those charges for Sirrus Web Technologies service that I may accure from month to month or any past due balances in order to bring the account in current status. This authorization is valid until revoked in writing.

Authorized signature: _________________________________

This form MUST be either mailed or faxed to Sirrus Web Technologies immediately in order for your account to be started on our servers. This process is included to protect both you and Sirrus Web Technologies. We assist in the prosecution of fraudulent use of credit cards.

Fax to: 909-484-3547
or Mail to:

Sirrus Web Technologies
8780 19th Street
Suite 345
Alta Loma, Ca. 91701

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