Pay by Automatic Withdrawal

Authorization Form For ACW (automatic checking withdrawal) / ACH

Instructions -- fill out on-line then print (ctrl-p),
sign, attach voided check and mail.

Name:

Company:

Phone Numbers:

E-mail:

Address 1:

Address 2:

City State: Zip Code:

Country:

The following ACW / ACH fees are charged monthly unless otherwise agreed to by Host2Host and Customer.

-- -- Note to ND Residents: 6% sales tax will be added. ACW / ACH Payments are withdrawn on or about the 1st business day of each month of service.

I (We) hereby authorize Host2Host to initiate debit entries to my/our:
(Select One) checking account savings account
.... and the BANK / DEPOSITORY named below, to debit the same to such account.

If you are not sure where to find routing and account numbers on your check, Click Here, a picture of a sample check will be displayed in your browser window with the typical locations listed.

Your Bank's Name:
Bank Contact:
Bank Phone:
Bank Address:
Bank City:
Bank State:
Bank Zip Code:
Account Number:
Name on Account:
9 Digit Routing Number:

I agree to the terms of the recurring monthly charges above and I have agreed to abide by the terms of the Host2Host Web Hosting Agreement by signing and dating such document.

This authority is to remain in full force and effect until Host2Host and BANK / DEPOSITORY has received written notification from me / us of its termination in such time and manner as to afford Host2Host.com and BANK / DEPOSITORY a reasonable opportunity to act on it.

Customer Name Printed

Today's Date

___________________________________________

________________

Customer Signature

Date

Staple a voided check to this signed document and return to:

Host2Host
c/o New Accounts
1119 Univ. Dr., #1503
Bismarck, ND 58504-6613

Note: Please return the completed form to Host2Host.com by the 20th of the current month in order to start the automatic withdrawal (ACW / ACH) plan the month following.