Below you will find our authorization form that you will need to print out and fax/mail back to us no later than 7 business days after your hosting account has been activated. This form gives Adult Virtual Hosting/Internet Services authorization to automatically bill the credit card of your choice each month when your hosting fee is due. This form MUST be completed in order for your account to remain on our servers. If this form is not returned during this period, your account will be disabled until this information is received. If you have any questions: accounting@adultvirtualhosting.com .

Internet Services
C/O Adult Virtual Hosting
P.O. Box 237
Woodbridge, VA 22194
Fax: (413) 425-8918
Fax: (800) 861-0956

Domain Name: _________________________________

Hosting Plan: _________________________________

Billing Charge: _________________________________

Cardholder Name: _________________________________

Cardholder Billing Address: _________________________________

City State Zip Code: _________________________________

Country: _________________________________

Credit Card Number: _________________________________

Expiration Date: __________

Credit Card Type (circle one): Visa Master Card American Express Discover

Cardholder Telephone Number: ________________________________

E-mail address for billing issues: ________________________________

To authorize billing to the above credit card, please sign below:

X_____________________________________________(Cardholder Signature)

My signature states that I authorize Adult Virtual Hosting/Internet Services to charge webhosting fees to my credit card as specified above. These charges will occur monthly until I cancel my account. I understand that I have the option to use a different form of payment as long as I notify Adult Virtual Hosting/Internet Services within 24 hours of my billing renewal date. This authorization is valid until revoked in writing.

**All cancellations must be received in writing by the 1st of each month. Acceptable forms of cancellations are regular mail, fax, or e-mail. Phone requests will not constitute acceptance of any cancellation.**