Computer Medic, Inc.




	Package Plan Click here for printable version Package Selected: Silver, Gold, Platinum, Email Only Billing Cycle Desired: Monthly, Quarterly, Semi-Annually, Annually Billing Method: Check/Cash Credit Card Name on Credit Card: ___________________________ Address on File with Credit Card Company: ____________________________ ____________________________ ____________________________ ____________________________ Credit Card Number: _____________________________ Expiration Date: ________________ CVV2 Number: ______ Name of Bank: __________________________ Domain Desired: _______________________________ Account Password Desired: ______________________________ Company Name: ________________________________ Contact Name: _______________________________ Address: ______________________________ ______________________________ ______________________________ ______________________________ Phone Number: ____________________________ Email Username Desired: _________________ Password: _______________ Email Username Desired: _________________ Password: _______________ Email Username Desired: _________________ Password: _______________ Email Username Desired: _________________ Password: _______________ Email Username Desired: _________________ Password: _______________ Email Username Desired: _________________ Password: _______________ Email Username Desired: _________________ Password: _______________ Email Username Desired: _________________ Password: _______________ Email Username Desired: _________________ Password: _______________ By signing below, you agree to pay the rates as set forth in the hosting rates as well agree to the online agreement, billing policy, and acceptable use policy incorporated by reference. If using credit card, you agree to allow Computer Medic, Inc. to process credit card payment on or about (but not before) the desired anniversary as set forth in this form. Signature: __________________________________ Name: _______________________________ Date: _______________