PZ Credit Card Payment by FAX

(This form must be completed in full and only sent via fax to 888-820-7333 or by postal mail.)
**Emailed orders will not be accepted**

Cardholder’s Name: _____________________________________________________
(As appears on the card)

Company Name: _______________________ Domain Name: ____________________

Street Address: ___________________________________________________________

City: _______________________ Province: _____________ Postal Code: __________

Phone: _________________ Fax: _________________ Email: ______________________

I hereby authorize PZ Internet to charge my:

[ ] VISA [ ] Mastercard [ ] American Express

the total amount of $ __________ (Canadian Dollars)

Payment for Invoice # __________

Card Number: ____________________________________

Expiry Date: _____ / _____
(mm / yy)

Last 3 digits on signature panel (on the back of card): _________

Card Holder’s Signature: ______________________________________ Date: _____________

By submitting this credit card authorization form, I agree to have benefited from the services provided
to me by PZ Internet, and agree wholly the amount charged to me as shown above. I also agree to
abide by the PZ Internet terms and conditions of service as posted at
http://www.pzinternet.com/termsandconditions.html