Web Hosting Form

Name *

First

Last

Email *

Organization Name

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Website to be hosted and maintained:

Credit Card *

Card Number

Security Code

Name on Card

Expiration/

Signature

Agreement: Web hosting is month-to-month and can be discontinued at any time with 30-days written notice. By signing this form, you provide your consent for Zynergy Ventures, LLC to bill the credit card provided. You agree to pay the monthly cost of hosting and maintaining your website until a cancellation notice is provided. Billing is conducted at the 1st of every month.

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